Date of Award

January 2022

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Louise-Marie Dembry


Introduction: In healthcare, normalized deviance is characterized by the steady transition away from standard practice toward variations in practice behaviors. This deviation presents minorly at first and is accepted to save time and increase efficiency. However, initial evaluations of innocuity do not represent actual safety. While the deviant practice may not cause immediate patient harm, its alignment with additional system weak points has the potential to lead to poor patient outcomes, including the development of healthcare-associated infections (HAI). One behavior that may influence HAI development and patient outcomes is hair removal during preoperative skin preparation.Methods: An observational study of hair removal during preoperative preparation in holding was conducted to identify abnormalities in the preoperative hair removal process at an urban, specialty orthopedics hospital in the United States. 129 observations were recorded across a five-week period between June and July of 2021. A subsequent literature review on preoperative hair removal and normalized deviance was conducted to identify relevant literature and develop recommendations. Results: 81 observations (62.79%) were found to have improper hair removal technique, compared to facility standard operating procedures and recommended practice. Improper technique was associated with variations between individual staff members in bivariate testing (p=<0.001), and there was a trend toward significance when evaluating the association between improper technique and holding unit (p=0.067). Scratches and abrasions to skin were also associated with improper technique and only observed when improper technique was used (p=0.003). Literature review identified 32 relevant articles for use in this study. Conclusion: Infection prevention and healthcare epidemiology teams should be prepared to identify and correct normalized deviance through education, engagement, and training via interdepartmental coordination. Further research into the connection between normalized deviance and patient outcomes presents a pressing issue for the future of these fields.


This is an Open Access Thesis.

Open Access

This Article is Open Access