Doreen Norton OBE,MSc,SRN,FRCN (1922–2007): Pioneer who revolutionised pressure sore management and geriatric nursing to international acclaim

Doreen Norton (Figure 1) was born on 1 May 1922 at Burr Villas, Hodge Place Road, Stone, Dartford, the older daughter of Henry Thomas Norton, a refrigeration engineer and Winifred Clara Norton, née Skinner, a mental nurse. ¹ She left school at the age of 14 years and worked in her father’s engineering business for the next six years. While this gave her a feeling for mechanical things, an admission to an isolation hospital with scarlet fever at the age of 11 years made her determined to be a nurse.

Basic nurse training began in 1942 at St Charles Hospital, London, the first of many London County Council (LCC) hospitals in which she was to work. ² It was damaged during the war, parts of it were closed, and its emergency services were transferred to Horton Mental Hospital, Epsom. ³ As soon as Norton had completed her initial training, she was sent, as first year probationer, with colleagues to Horton. There was no further training and she was thrown in at the deep end, making the whole thing ‘a nightmare’. After eight months, she resigned and returned to St Charles Hospital where she worked in an old people’s ward located in the basement of the hospital. ⁴ These were known as ‘punishment’ wards: apparently for both patients and nurses! On the one hand, they were a repository for ‘bed blockers’ and, on the other, a ward for nurses who had displeased the authorities in some way such as breaking hospital rules, were considered clinically unsafe to work elsewhere or had abandoning nursing and were working their notice. It was here that Norton learnt the basic principles of nursing care unencumbered by medical staff who rarely visited. The matron told Norton that if she could learn to nurse old people she would be able to nurse any patient with any condition anywhere. She loved this work and was much happier. OPEN IN VIEWER

Figure 1.

Doreen Norton. Published by permission of the RCN Publishing Co.

Norton commented that this was the period in the history of the nursing profession when the nursing staff were steeped in the tradition of custodial care for the chronic sick, when junior nurses were firmly disciplined, were resident, and if they got married they had to leave. They were not expected to question treatments, ward routines, or teaching methods. Bedsores were treated with spirits and soap applied with circular movements and rubbed in. Most patients were kept in bed, made comfortable, and one ward round was devoted to ‘cleaning up’. When the new style of care of the elderly (geriatric medicine) was first introduced, the nurses were given no training or explanations other than to get everybody up. Not surprisingly, patients, who had been in bed for years, cried when this happened while other disabled stroke patients were hurt when nurses tried to get them into bed jackets. Many nurses deemed this ‘modern’ treatment as cruel!

Norton qualified as an SRN with distinction in 1946 and for the next 10 years extended her professional experience. Initially, she worked on tuberculosis wards which she found very exciting. Unfortunately, she contracted the disease which required a year’s hospital treatment in Sidcup. There she was visited by the author Monica Dickens (1915-1992) and remained in contact with her for many years. In 1951 she obtained her TB nursing certificate with honours, a Hospital Saving Association Scholarship and was appointed sister on the new thoracic surgical unit at Colindale Hospital. ⁵ She drew on these experiences to compile Aids to Thoracic Nursing. ⁶

However, her conscience pricked her and she returned to geriatric nursing at St Charles Hospital. The nursing and medical staff were generally unenthusiastic about the new style management of the chronic sick. She visited Dr Marjory Warren, the pioneering geriatrician at the West Middlesex Hospital, who gave great encouragement although nurses found her rather intimidating. ⁷ She mobilised only those patients she thought suitable and was supported in her approach by the Matron.

In 1952, Norton left the NHS for a year to join her younger sister, Joan, to look after their mother who was severely disabled with painful rheumatoid arthritis and unable to stand. She applied the lessons she had learnt during her nursing career, adapted the house and furniture, brought the toilet downstairs and raised its seat. Surgeons were persuaded to straighten her mother’s knees. This enabled her to climb stairs and to have a much more active, pain-free life. Norton described these successes in a book, Looking after old people at home, which was packed with much shrewd advice and went into three editions. ⁸ Following its publication, she gave many BBC interviews and received a very substantial mailing from a receptive audience.

In 1953, Norton returned to the NHS and was appointed to the geriatric outpatient department at Edgware General Hospital. ⁹ There she met the local geriatricians: Drs Alan Binks and Monica Stewart, and an enthusiastic physiotherapist, Margot Hawker. ¹⁰ By 1956, she realised that she did not know how older people managed at home and so she worked for two years as a social worker for King Edward’s Hospital Fund assessing elderly people on waiting lists for admission, who were generally considered likely ‘bed blockers’. However, she acknowledged that the Fund had to keep a tight restraining rein on her because she would keep helping those patients she was supposed to assess.

This work led to a momentous meeting with Dr (later Professor) Arthur Exton-Smith which was to bring her international renown. ⁹ He obtained a £5,000 grant from the National Corporation for the Care of Old People (NCCOP) for her and her colleague, Sister Rhoda McLaren, to carry out a two-year study of nursing elderly patients based at the Whittington Hospital, London. This was the first time research funds had been awarded to a nurse. The aims were to improve nursing techniques of the elderly sick, to provide greater comfort to patients, to increase independence, and to reduce nursing workload. She received considerable encouragement from Exton-Smith for whom she had great respect. Although he called her Doreen, it was many years before she felt comfortable in calling him Norman.

The results of this seminal work, An Investigation of Geriatric Nursing Problems in Hospital, were published in 1962. ¹² It was the first research of its kind in the UK and emphasised the need to group beds according to the patients’ needs whether assessment, continuing, or long stay care. It highlighted the problems and the correct management of pressure sores. It firmly established the Norton Pressure Sore Scale as a valuable nursing tool. Following publication, the NCCOP employed Norton to respond to over 167 requests from matrons and ward sisters to speak on the subject.

Between 1963 and 1964, Norton was a nursing research officer at the Royal College of Art, School of Industrial Design. The College had been commissioned by the King’s Fund first to find out what was wrong with the current range of more than 300 different types of hospital beds, which lacked standardisation, and second to design a new bed. She joined the eminent team of Professor Bruce Archer, Gillian Patterson, and Kenneth Agnew. ¹³ Norton’s knowledge of nursing and ward practice proved decisive at an early stage because she was seen as representing ‘user needs’ that were central to Bruce Archer's design methods. Their project culminated in the design of what became known as ‘the King’s Fund Bed’: a general ward bed, easily movable, height adjustable over a large range, with a reclining back-rest and easily tiltable by foot pedals at floor level.

In 1964, she returned to Edgware General Hospital as nursing researcher supported by a Nuffield Foundation grant of £6,750. She assessed practical nursing problems and their solution in long-term patients in 300 hospitals. The report, Hospitals of the Long Stay Patient; a study of the nursing problems and solutions, was published in 1966. ¹⁴ She presented a paper on the subject to the 7th International Congress of Gerontology in Vienna in the same year. ¹⁵ She used the opportunity to underline negative attitudes towards sick elderly people who might be accommodated in inadequate hospital buildings that lacked proper equipment.

Norton’s attraction towards nursing research continued unabated. In 1966, she moved to the Department of Nursing Studies at Edinburgh University, attracted by the opportunity of studying for an MSc, which she successfully completed in 1969. The research, on basic nursing equipment, was published in 1970. ¹⁶ The Scottish Home and Health Department seized the opportunity to employ her, seconding her to the Scottish Hospital Advisory Service which in turn orchestrated visits to every long stay hospital in Scotland. From 1973 until 1982 when she retired, she was Nursing Research Liaison Officer, and later Chief Scientific Advisor for clinical nursing research, for the South West Thames Regional Health Authority. She started work on a PhD, but regretted never completing it.

During her professional career, she advised health authorities, the Design Council, the Disabled Living Foundation, and manufacturers of equipment for the disabled, assisted in planning hospitals, and was a member of editorial boards and national committees. She lectured extensively in the UK and abroad, particularly New Zealand and Australia, gave many talks on the BBC, and published books, important reports and many articles. She always acknowledged the considerable ‘backroom’ assistance she was given by her sister, Joan.

Doreen Norton's professional philosophy

Norton contended that nursing care of old people had not ‘moved with the times’. Old-fashioned concepts of management were slow to be eradicated.

The elderly at home

Norton advised elderly people and their carers on how to manage at home. ¹⁷ She emphasised that older people could be fit, active, and ‘life could be added to years’ by maintaining good health, being happy, and continuing outside interests. Her general advice ranged from sensible floor covering, a wise diet, adapting furniture and cutlery, walking aids, clothing and bathing, to nail care. Problems with dentures, eyesight, and hearing should always be referred to appropriate professionals.

Illness in older people at home often aroused sympathy and a willingness to help but could present burdens for carers. Simple nursing care was largely a matter of common sense, but carers needed instructions regarding the correct way to lift patients to prevent incurring their own back problems. She recommended methods for preventing pressure sores and overcoming an unwillingness to get out of bed.

The elderly in hospital

Norton defined ‘geriatrics’ as the positive approach to preserve and to restore human ability in old age. The care of old people in hospital should be based on education, modern facilities, and quality research.

Education, the first strand of her beliefs, was most important and involved both pupil nurses and teachers. A change of heart and attitudes towards the nursing of the elderly sick was essential: first, to acknowledge that they were not ‘second class’ patients, and second to nurse them in an appropriate manner. She accepted that nursing older patients could be arduous, monotonous, time consuming, heavy, sometimes revolting, thus placing demands on the endurance and patience of the caring staff, but it could be rewarding and of great interest.

Norton believed that no nurse should be launched into the world as qualified without having had geriatric nursing experience. Lectures on geriatric nursing should be the norm in the nurse-training syllabus. Old established ideas that chronic sick patients only required toileting and feeding should be dismissed. Knowledge of the patient’s social circumstances was equally important for successful nursing.

Nursing tutors needed experience in geriatric nursing and should emphasise that the signs and symptoms of disease in old age could be quite different from younger people. Nurses had to adjust their management style of nursing according to whether the patient was in an acute, rehabilitation, or continuing care ward. A balance was required between giving tender loving care and helping the patient maintain independence.

Unfortunately, authorities were slow to enforce improvements in geriatric teaching. In 1971 the General Nursing Council syllabus included geriatric nursing but it did not become compulsory until 1979. The Joint Board of Clinical Nursing Studies provided courses in geriatric nursing but these were largely ignored. Project 2000 failed to place geriatric nursing as a specialty on the same basis as that of paediatric nursing. Many recommendations to improve patient/nurse ratios were also largely disregarded. ¹⁸

The second strand of Norton’s philosophy was the provision of modern accommodation and appropriate equipment. Hospital authorities had to realise that ancient buildings, often sited in remote areas, and lack of basic equipment did not meet the needs of contemporary geriatric nursing. Money spent on aged facilities would not cure fundamental problems of narrow stairs, corridors, and lack of floor space. The absence of passenger lifts made delivery of meals and supplies difficult and resulted in patients and bodies being ‘man handled’ down external fire stairs. Heavy lifting equipment to avoid back injuries to caring staff, appropriately designed modern baths and ward equipment were all fundamental to good quality care.

Last, Norton was convinced that research in geriatric nursing was essential and could be very productive, as her own work had shown. She was pleased that the volume of research material produced by colleagues was eclipsing that produced by other specialties.

Recognition

Doreen Norton was elected as one of the first fellows of the Royal College of Nursing (RCN) in 1976 and was appointed OBE in 1977. Between 2002 and 2004, she received the first ever lifetime achievement award from the British Journal of Nursing, opened a 24-bedded ward at University Hospital, Lewisham, which had been named after her, and was awarded an honorary fellowship by London’s South Bank University, where an annual research lecture was set up also in her name. She was founder member of RCN Nursing Research Society, founder chairperson of the College’s Society of Geriatric Nursing and a member of ‘the Propers’. ¹⁹

Within a year of retirement, she was invited to take the Chair of Gerontological Nursing at the Case Western Reserve University in Cleveland, Ohio: the world’s first such post, which she held until 1984. Once again she helped on the wards much to the exasperation of the university authorities who told her she was there to teach and not to be ‘hands on’. The experience was not entirely to her liking: she lost weight and went home for a few months to recuperate before returning to the fray.

Looking back

Norton was an energetic, attractive lady with a delightful personality. She was passionately devoted to improving the nursing care of elderly patients, developing appropriate ward equipment and perfecting nursing procedures. She believed the story of geriatric nursing was one of ignorance and educational neglect by the nursing profession and she considered that every qualified nurse and nursing tutor should have experience in nursing elderly patients. Her commitment to the care of older people brought national and international recognition and acclaim.

Her final publication was The Age of Old Age where she logged the advances made in modern care of the older person. ²⁰ She noted the lack of a comprehensive book on geriatric nursing but did not write one herself. She acknowledged that some advances in the care of older people had been made but was sorry that the term ‘geriatrics’ now referred to anyone of no apparent value. In her latter days, she became more disheartened, believing that advances in care had become as ‘footprints in wet sand’: achievements were lost as if they had never happened. ²¹

She died in a nursing home in Worthing, Sussex on 30 December 2007 from an intracerebral haemorrhage. She did not marry and was survived by her younger sister, Joan.