In the most basic sense, the current global nursing shortage is distinctly a widespread and dangerous lack of professional and skilled nurses who are needed to care for individual patients and the population as a whole. These causes include nurse short-staffing, inappropriate resources for nursing research and education, the increasing complexity of health care and care technology, and the speedily aging populations in developed nations. Because studies have shown that an inadequate quantity of professional nurses in clinical settings has a significant negative impact on patient outcomes, including mortality, the nursing shortage is literally taking lives, and impairing the health and wellbeing of many millions of the world’s people. It is a global public health crisis (ICN, 2004).

There is a predicted shortfall of qualified nursing staff in both low and high-income countries. The growing shortage of health care workers has become an international challenge (Sorgaard, 2010).

The authors believe that Saudi Arabia is not exempted to the current global nursing shortage due to lack of professional nurses. To understand the Saudi shortage in nurses, one has to understand the Saudi dependence on foreign nurses. Saudi education system has only focused on high paid, prosperous, and prestigious jobs like doctors, engineers, and lawyers and left basic yet complementary job as nursing way behind. This lack of attention to necessary and complementary jobs, has led the Saudi education system in creating less than 20 percent of the nursing staff working in Saudi today, which in return led into today’s significant shortage in qualified and competent Saudi nurses and to high rate of foreign nurses (Aldossary, 2008). While the institute program in Saudi Arabia consists of nursing studies for three years and results in a diploma in nursing. The program prepares nurses to assume roles as technical nurses, considered by some to equate with that of a practical nurse in the United States (Tumulty, 2001).

In the United States, there are registered nurses (RN’s) or Professional Nurses and practical nurses (PN’s) or LVN (Licensed Vocational Nurse) / LPN (Licensed Practical Nurse), CNA(Certified Nurse Assistant) also called “vocational nurses” (VN’s), or Practical Nurses. While registered nurses are able to perform certain duties or provide treatments that practical nurses cannot, such as administering blood, this is not what primarily sets them apart. The most notable difference is in the education they receive. As far as the scope of practice is concerned, each state has a separate nursing board which governs what nurses are legally able to do (Ellis & Hartley, 2004). In the hospital setting, professional /registered nurses are often assigned a role to delegate tasks performed by LPNs and non-professional unlicensed assistive personnel such as nursing assistants (Ellis & Hartley, 2004).

Skilled nursing of a professional nurse is vital to the patient outcome (Gordon, 2005). But due to economic crisis and poverty, significant work must be done to have more professional nurses. Graduates, due to poverty and worldwide economic crisis prefer to have non-professional program to quickly acquire work due to the short courses offered in non-professional programs. (Turale, 2010).

Therefore, the authors believe that whether a nurse is a professional or practical, all nurses must remember as what has been stated in nurses’ pledge by Florence Nightingale: “I solemnly pledge myself before God and in the presence of this assembly to pass my life in purity and to practice my profession faithfully. I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling” (American Nurses Association, 2010).


The following different levels of Nursing Education gives us the background on the difference between a professional and vocational nurses:

Nursing Assistants are defined by law as people who assist licensed nursing personnel in the provision of nursing care. The authorized duties for a Certified Nursing Assistant (CNA) include assisting with their client’s daily living activities, such as bathing, dressing, transferring, ambulating, feeding, and toileting. CNAs also perform tasks such as measuring vital signs, positioning and range of motion. Their duties are limited to tasks commissary by the registered or licensed practical nurse in acute-care field, their tasks such as vital signs, assessing patients’ well-being, administering hygienic care, assisting with feeding, giving basic psychosocial care, and similar duties. Diploma degree are hospital based educational programs that provide a rich clinical experience for nursing students. These programs are often associated with colleges or universities. Baccalaureate degree programs located in senior colleges and universities and are generally four years in length. Masters programs provide specialized knowledge and skills that enable nurses to assume advanced roles in practice, education, administration, and research (NWJobs, 2010).

The Doctor of Nursing Practice (DNP) is an advanced-level practice degree that focuses on the clinical aspects of nursing rather than academic research. The curriculum for the DNP degree generally includes advanced practice, leadership, and application of clinical research. The DNP is intended primarily to prepare registered nurses to become advanced practice nurses. Advanced practice roles in nursing include the nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified nurse midwife (CNM), and the clinical nurse specialist (CNS). Nurse anesthetist programs may use the title Doctor of Nurse Anesthesia Practice (DNAP) for their terminal degree. According to the American Association of Colleges of Nursing (AACN), transitioning advance practice nursing programs from the graduate level to the doctoral level is a response to changes in health care delivery and emerging health care needs, additional knowledge or content areas have been identified by practicing nurses. In addition, the knowledge required to provide leadership in the discipline of nursing is so complex and rapidly changing that additional or doctoral level education is needed (Dracup, 2005).

At the moment only fewer Saudi nurses had bachelor of science, master’s or doctoral degree, but the government start to increase and expand. A lot of nursing continue lead degree will be graduated within few years to assume leadership position in the health field. The kingdom has a great need for well educated Saudi nurses (Tumulty, 2001).

However, in recent years, questions have been raised about whether nursing is a profession or an occupation. This is important for nurses to consider for several reasons, starting from differentiating the terms ‛profession’ and ‛occupation’, ‘professional and ‛vocational nurse’. An occupation is a job or a career, whereas a profession is a learned occupation that has a status of superiority and precedence within a division of work. In general terms, occupations require widely varying levels of training or education, varying

levels of skill, and widely variable defined knowledge bases. Indeed, all professions are occupations, but not all occupation is profession (McEwen ,2007).

Therefore based on ‛nursing as an occupation’, a professional nurse is a healthcare professional who, in collaboration with other member of a healthcare team, is responsible for treatment, safety and recovery of acute or chronically ill individuals; health promotion, and maintenance within families, communities and population; and treatment of life-threatening emergencies in a wide range of healthcare settings (Craven, 2009).

Current Shortfall in Workforce and Education

The number of nurses currently in the workforce based on their educational preparation: those with undergraduate education (diploma, associate, baccalaureate degrees) and those with graduate education (master’s and doctoral degrees) Health Resources and Services Administration. Much higher number of nurses prepared at the diploma/associate degree level compared to all other categories and the relatively small number of nurses prepared with graduate degrees. The limited number of nurses prepared with graduate degrees presents a significant problem for educating future nurses and furthering effective nursing practice; master’s-prepared clinicians are needed to teach and provide primary care, and doctoral faculty are needed to teach and conduct research. Without an adequate number of nurses prepared at the graduate level, we will be unable to educate enough nurses to meet the demands for care at all levels in the near future. Experts predict we will experience a nurse shortage of anywhere from 340,000 to more than 1 million by 2020; shortages will occur in hospitals, in nursing homes, in home health care, and community health centers (HRSA, 2010).

Nurse shortage projections are based on the increase in anticipated demand for health care demands that are projected to increase dramatically due to our aging population and higher numbers of insured patients with access to care as a result of a reformed health care system (Knowledge&Wharton, 2009). The percentage of the population 65 years or older steadily increases as the baby boomer generation approaches age 65; by 2030, twenty percent of the population will be above the age of 65, almost doubling the current rate of twelve percent (Peterson, 2003).

As the population ages and health care resources become more strained, the focus and location of care delivery will need to change from acute care provided in hospitals to primary care, which includes disease management, care coordination, and prevention of disease delivered in community settings, in clinics, ambulatory care centers, and in the patient’s home. In the future, we will need many more advanced practice nurses (nurse practitioners, nurse anesthetists, nurse midwives, and clinical specialists) to assume a greater responsibility for the delivery of health care (Peterson, 2003).

Need for Education in Nursing, Master’s, Baccalaureate, and Doctoral

To design strategies that lead to an adequate nurse workforce, we first need to examine how nurses enter the workforce. The nursing profession is unique in its complicated mix of educational models, which is not only confusing to the public, legislators, nurses, and potential nursing students but also contributes to a lack of professional unity and professional recognition. As a result, nurses are fragmented in their interests and do not have the political clout of other professions when advocating for patients or better working conditions.

The recognition of the need for baccalaureate nurse education is not new. In 1920, the Goldmark Report, funded by the Rockefeller Foundation, proposed educating nurses in academic institutions along with other professionals, arguing that this would more adequately prepare nurses to meet the needs of society and improve the status of the nursing profession (Ellis, 2004). At that time, nurses were being educated in hospital-based diploma schools that continued to be the major provider of nursing education until associate degree programs began in the 1950s. Associate degree nursing education was proposed as a solution to a severe nursing shortage (Fondiller, 2001). In 2004, the American Organization of Nurse Executives (2004) argued for baccalaureate-level educational preparation for all future nurses. Furthermore, the baccalaureate degree was needed for nurses to function as an equal partner in patient care. Most recently, the Carnegie Foundation report, “Educating Nurses: A Call for Radical Transformation,” called for significant changes in nursing education with the establishment of the baccalaureate degree for entry into professional nursing practice being a necessary first step. The report falls short however in recommending more of the same, by calling for the creation of a more seamless transition from ADN to BSN programs (Benner et. al., 2009).

A large amount of empirical evidence exists to support a difference in performance and patient outcomes. In 1988, Johnson published a meta-analysis of 139 studies exploring the differences in associate and baccalaureate performance. These studies revealed significant differences between associated degree in nursing, and bachelor of science in nursing (BSN) nurses, with baccalaureate-prepared nurses demonstrating greater professional performance in the areas of communications skills, knowledge, problem solving, and professional role. In 2001, Goode and colleagues surveyed 80 chief nursing officers from academic medical centers to determine their perception of differences in nurse performance based on education level. Respondents reported that baccalaureate-prepared nurses demonstrate greater communication, coordination, and leadership skills; more professional behavior; and a greater focus on patient psychosocial care and patient teaching than associate-prepared nurses (Goode et al., 2001).

Although estimates vary on the need for more health care providers in the future, there is agreement that a shortage of primary care providers currently exists in rural and other underserved areas (Kirch & Vernon, 2008) and severe future shortages predicted in community health centers (National Association of Community Health Centers, Robert Graham Center, & The George Washington University, 2008) and in the country’s more than 6,080 designated primary care shortage areas in the United States (HRSA, 2006).

A major contributing factor to the current and future nurse shortage is the lack of nursing faculty available to educate nurses. The student demand for nursing education is currently at an all-time high, but a faculty shortage has created a severe bottleneck in nurse education, leaving nursing schools unable to meet the demands for education. An estimated 50,000 qualified applicants were turned away from baccalaureate nursing programs in 2008, primarily due to faculty shortages. Of the Eighty-four percent of U.S. nursing schools in 2006-2007 attempting to hire new faculty, Seventy-nine percent reported difficultly in recruitment due to a lack of qualified candidates and the inability to offer competitive salaries. In their 2007 annual survey of colleges of nursing, the National League for Nursing (NLN) reported 1,900 unfilled faculty positions nationwide, an increase of Twenty-three percent from the previous year in the number of full-time faculty vacancies and a disturbing trend in the shortage cycle (2007). An estimated 25,100 nurses have doctoral degrees, and their numbers are not increasing at the rate needed to meet demand. From 2003 through 2008, the number of nursing PhD graduates increased on average by about Thirty-one new graduates each year. Disappointingly, enrollment in PhD nursing programs increased by only 0.1% or 3 students from the fall of 2007 to the fall of 2008 with the total doctoral student population in 2008 reaching 3,976 (AACN, 2010).

Contribute to an alteration of what is considered to be necessary qualifications among nursing staff. This may cause additional strain on the substantial proportion of clinically oriented staff who lack formal (nursing) qualifications. We believe the importance of the present study lies in the focus it has on working conditions of sub professionals in acute psychiatry. As we have argued above, there is an increasing and probably worldwide lack of nursing staff in the health services and increased use of health care assistants is reported (Spilsbury, 2004). Although the evidence on a general level suggests that more use of less qualified staff will not be effective in all situations (Buchan, 2002). Due to what is said above it is increasingly important to recruit, retain and qualify also sub professionals, and a condition for this is the quality of their working environments.

patients and patients care

The authors believe that nursing care is a critical facet of health care, it has an impact on all aspects of the business of hospital and community care. In hospitals it must be provided over a full 24 hour period, every day of the year. If it is not present neither patients nor other health professionals will be satisfied with the service provided.

A professional nurse is accountable for embracing professional values, maintaining professional values, competence, and maintenance and improvement of professional practice environments, also nurses is accountable for the outcomes of the nursing care. Increased knowledge on germs and diseases, and increased training of doctors, nurses needed to understand basic anatomy, parhophysiology, physiology, and epidemiology to provide better care. To carry out a doctor’s orders, and must have some degree of understanding of cause and effect of environment (Finkelman, 2010).

Quality of Care

The quality of care can be more precisely described as seeking to achieve excellent standards of care. It includes assessing the appropriateness of medical tests and treatments and measures to improve personal health care consistently in all areas of medicine. Nurse’s professional socialization is recognized as an essential process of learning skills, attitudes and behaviors necessary to fulfill professional roles are also involved in evaluating and modifying the overall quality of care given to groups of clients. One of the essential parts of professional responsibility, nurses and all other health care providers work together as an interdisciplinary team concentrate on improving client care (Kozier, 2008).

Despite widespread efforts to address serious gaps in the delivery of safe, efficient, and quality patient health care (Institute of Medicine, 2000, 2001), suboptimal and preventable adverse patient outcomes occur too often in the United States (Institute of Medicine, 2004). Between 2004 and 2006 alone, patient safety incidents in hospital systems resulted in an estimated 238,337 potentially preventable deaths (Health Grades, 2008). The nation’s nursing shortage has exacerbated the problem, and projections indicate a deficit of 260,000 nurses by 2025 (Buerhaus et. al, 2009).

A divergence between demand and supply that is evidenced in insufficient nurse staffing with significant implications for patient quality is what Nursing profession faces continuously. Many believe this shortage of registered nurses is entrenched in long-standing problems related to the value and image of nursing and the limited role nursing has had in identifying priorities within health care delivery systems (AACN, 2010).

Many institute graduates are relegated to functioning at a level barely above a nurse aide. Thus, the already scarce Saudi nurses are disadvantaged and underutilized. Saudi Arabia is increasing its proportion of indigenous nurses who will be able to deliver culturally appropriate high quality care (Aldossary, 2008).

The author predicted shortfall of qualified nursing staff in both low and high-income countries. Restructured health care systems and social values has made lack of nursing personnel which concern for health care administrators, politicians and the nursing professions. The shortage in health care workers growing and has become an international challenge (Sorgaard,2010).

One of the central professional self regulation is the ability to maintain and control a professional register. To this end self regulating professions, like nursing, have been responsible for controlling their register which is done through the setting of the standards to be achieved before entry is possible . In addition, the professions also have responsibility for the removal of practitioners who are considered unfit to practise (Unsworth, 2010).

The quality of care requirements of the all of the health profession regulators and they have recommended that the term “good” in relation quality of care should be amended within the legislation to ensure that this is not used by other bodies as a bar to entry into the professions considerations about health are restricted to whether the individual’s health, with any necessary reasonable adjustments, would impair their fitness to practise. The notion of good character is based upon the requirement under the Code of Professional Conduct (NMC, 2008) for nurses and midwives to be honest and trustworthy. For an individual to satisfy the good quality of nursing care character requirements, they must be capable of safe and effective practise without supervision. This is, therefore, the threshold set by the regulator for any action which may be taken against an individual student in terms of their conduct. If the student’s attitude, behavior, conduct (including convictions) or quality of care calls into question their ability to satisfy the requirements of the quality of care and good character then action may be required to investigate the allegations and to make a determination about whether the nurses would be capable of safe and effective practise without supervision at some future point. The notion of “good character” has also been open to criticism not least because of difficulties in defining how a good character is measured (Sellman, 2007).

Aim / Objective:

To describe the impact of professional nurses and nursing education that affect the quality of care for the patients.

Research Qutcion

How does an RN’s educational level affect the quality of patient care?


Literature review is considered a baseline tool that precedes the actual qualitative or quantitative research. In order to have a research, the researcher needs to read the related articles that have researched the topic. The chosen method is a literature review which decided by authors to used as one method of final thesis. The important of using literature review in this research is to overview the evidence to the problem being addressed and to articulate the answer of the question of the study aim from different studies with creating a new finding. The literature review is defined as a written summary of the state of evidence on a research problem (Polit, & Beck, 2008).

Inclusion criteria

The authors collect all articles that were published written in English with relative to study aim. The limiting of the year of selecting articles is to found new finding from different studies with updated information. nursing articles, articles published after 2000, primary sources.

Exclusion criteria

The articles that are not relatively to the study aim should excluded and also any literature review articles. In addition, the authors exclude the articles that are sponsored by any company and excluded any articles published before 2000, secondary sources.

Database searching

PubMed and CINAHL: Mesh terms were used in this search. These words placed in PubMed to achieve the research aim as seen in table below. Searching in CINAHL was giving the similar articles but the difficulty to access these articles made the authors to continue searching in PubMed.

Data analysis

The authors have been chosen fifteen articles. Around Seventy-one articles were read in full text, Some of them did not serve the purpose and some were literature review. The fifteen articles were analyzed by beginning of extracting and validating the information contained and met the inclusion criteria. All articles have been read independently before, and then discussed their finding with each other. we started extracting data from articles through highlighting the important information which use of colors and numbering. Moreover, the information were selected are discussed between us and our Advisor Which excluded three of articles was changed and documented that in word document and aded to matrex.

Medical Subject Headings (MeSH)

The MeSH terminology is a vocabulary created by the National Library of Medicine using different terminology with same concepts (Polit & Beck, 2008). The MeSH terminologies were searching by authors used the PubMed databases to search for academics articles by a combination of (Professional Nursing, levels of Nursing Education, Nursing education and quality of care, Professional Nursing and quality of care). MeSH terms were used in this search. These words placed in PubMed to achieve the research aim as seen in table below. Searching in CINAHL was giving the similar articles but the difficulty to access these articles made the authors to continue searching in PubMed.

The literature review protocol

The literature review matrix was used to put all articles in systematic review and provide a structure in order to assess and evaluate the quality of scientific articles (Polit & Beck, 2008).

Classification of the scientific articles

The selected articles were assessed independently by the authors using

Appendix 1Sophiahemmet University College classification guide of academic articles and studies regarding quality in both quantitative and qualitative research (Appendix 1). The studies were classified as Randomised controlled trial (RCT), Clinical controlled trial (CCT), Non- controlled study (P), Retrospective study (R) or Qualitative study (Q). Scientific quality of the studies was assessed on a three-grade scale: (I) – high, (II) – moderate, or (III) – low quality. The authors` intended to work systematically by highlighting the similar words in the articles e.g., Professional Nursing, levels of Nursing Education, Nursing education and quality of care, Professional Nursing and quality of care, and then on a regular basis compare and discuss responses to the research questions. Research study was potentially relevant and focuses on studies and data extraction and analysis of results of the study where we have misled our study is consistent on the color yellow, and non-uniformity in the methodology and evaluation of high-quality study enables the reader to understand clearly., (1999) and Willman, Stoltz & Bahtsevani (2006). The authors ensured that the articles are have high quality in order to serve the goal of this research also, to make the results clear and based on strong evidence. So, the authors exclude the articles with moderate and low quality. Because we found a lot of high-quality research articles.


The ethical consideration is the method in how to analyze problems (Polit & Beck, 2008). The research ethics is all processes followed the codes and policies in research including the honesty of communications, report data, results, methods, procedures, and also the publication status and protect the privacy of communications. Moreover, the objectivity which is avoid the experimental design and all data including analysis and interpretation (Polit & Beck, 2008; Resnik, 2010).

The authors should consider the research ethics in all processes and follow the codes and Policies of research ethics including; Honesty in all scientific communications, report data, results, methods, procedures, and also the publication status, competency to maintain and improve our own professional competence through lifelong education and learning. Objectivity, disclose personal interests that may affect research. Respect for intellectual property, no plagiarism done by the authors (Resnik, 2010).

The author’s foundation from the article was clear and the researchers displayed respect for human dignity. The author did the job for searching by honest and professional way, without hidden or disappear any good or truth result (Polit & Beck, 2008). Authors followed the ethical principals in research, honestly, objectivity, integrity, carefulness, openness, and copyright. The authors going to select the articles which approved by ethical committee.


Appendix 1


Date for


Key words

Identified articles (hits)

Abstracts reviewed

Articles examined

Articles included


Professional Nursing






levels of Nursing Education






Nursing education and quality of care






Professional Nursing and quality of care