Abstract
A questionnaire, based both on Norwegian law and regulations and the nursing process model, was developed to describe the student nurses'preparedness for documentation of nursing care. It was also used to study the students' learning of documentation during their first clinical practice. The results showed that the opinion regarding the students' preparedness for nursing documentation differed. The students and their clinical supervisors felt they were more prepared than did the faculty teachers who were responsible for them in practice. Moreover, the student nurses' learning in clinical practice lacked the professional and systematic approach required for nursing documentation to be acceptable. A group of students using the VIPS model was compared with a control group using guides from the college or wards when they documented nursing care in a pedagogical nursing care plan. The students who used the VIPS model had a clearer structure and better results with regard to content than the students using other models.
The study resulted in the development of an instrument for guidance and evaluation in which all the components of the nursing process are combined with specific requirements as to the content of nursing documentation.