Identifying Key Competencies for Ambulance Nurses in Italy: Findings from a Modified Delphi Study

Abstract

Introduction

Prehospital emergency nursing is a critical domain requiring specialized competencies and robust clinical preparation. Nurses in this sector manage high-complexity situations necessitating a broad range of competencies. This study aimed to identify and validate the essential competencies required for specialized ambulance nurses in Italy using a modified Delphi methodology.

Methods

A Delphi study was conducted with a panel of 10 experts, including clinical practitioners and academic professionals. The study involved 2 rounds of questionnaires designed to gather and refine expert opinions on the competencies necessary for ambulance nurses.

Results

The experts identified a comprehensive set of 77 competencies across various domains, emphasizing advanced clinical competencies, decision-making abilities, communication, interpersonal competencies, and leadership. The first round highlighted 31 competencies from clinical experts and 46 from academic experts, with significant overlaps and some divergences. The second round achieved high consensus on many competencies, though some areas, such as holistic and spiritual competencies, showed varied levels of agreement.

Discussion

The identified competencies underscore the complexity and dynamic nature of prehospital emergency nursing. The results provide a framework for developing targeted training programs to prepare nurses for the demands of this field. Continuing education emerged as a crucial element for maintaining and enhancing competencies in the evolving landscape of emergency health care.

Contribution to Emergency Nursing Practice

• • Clinical competencies and reasoning are essential for effective nursing, contributing significantly to patient outcomes and high-quality care. Previous studies have underscored the value of these skills in clinical practice.
• • This paper presents an analysis of specific competencies required for ambulance nurses, identified using the Delphi method. It offers a competency framework focused on prehospital emergencies, highlighting clinical and decision-making skills.
• • The main implication is the establishment of a structured framework that guides the training and professional development of ambulance nurses. This ensures that they are well-equipped to provide quality emergency care, improving patient outcomes and enhancing emergency service efficiency.

Introduction

Nursing care in the context of prehospital emergency services represents a critical sector of contemporary nursing practice. Nurses operating in this environment are required to handle a wide range of high-complexity and high-criticality situations, necessitating specialized competencies and robust clinical preparation. ^{1 Prehospital emergency services refer to all medical and traumatic crises that require immediate intervention outside the hospital setting, such as road accidents, heart attacks, cardiac arrests, severe traumas, and other medical emergencies. 2 In this context, nurses play a fundamental role in providing timely and high-quality emergency care, ensuring the well-being and survival of patients. 3}

The importance of nursing competencies in the prehospital emergency setting has been widely recognized in the scientific literature. Nurses working in this sector must possess a broad range of clinical, decision-making, communication, and management competencies to address this environment's unique and dynamic challenges. The competencies required for nurses in prehospital emergency care include the ability to rapidly assess patients’ clinical status, stabilize critical medical conditions, manage trauma, communicate effectively with patients and team members, and make quick and accurate decisions under pressure. ^{4 , 5 Additionally, nurses must be able to work collaboratively within multidisciplinary teams and adapt to changing and unpredictable situations. 6}

A distinctive aspect of nursing practice in prehospital emergency care is its dynamic and adaptive nature. Nurses must be prepared to face a wide array of scenarios and situations, often with limited resources and in challenging environmental conditions. This flexibility and resilience require adequate training, preparation, and continuous professional development. ^{7 Furthermore, the evolution of technologies and best clinical practices necessitates that nurses remain constantly updated on the latest evidence and intervention methodologies. 8}

Research on nursing competencies in prehospital emergency care has significantly contributed to understanding this critical sector of nursing practice. Previous studies have identified a range of key competencies required for nurses operating in this context, including advanced clinical competencies, rapid decision-making abilities, practical communication competencies, and teamwork capabilities. ^{9 However, much remains to be learned about the best practices in training, acquiring, and maintaining these competencies and their impact on care quality and patient outcomes. 10}

Prehospital emergency care represents a unique and challenging area of nursing practice. It is characterized by a wide range of medical and traumatic situations that require timely and competent interventions outside the hospital environment. ^{11 , 12 Nurses operating in this sector must possess a broad spectrum of clinical, decision-making, communication, and management competencies to ensure the delivery of high-quality emergency care and the well-being of patients. 13}

Despite the increasing recognition of the importance of ambulance nurses in prehospital care, there is limited research focusing on the specific competencies required in Italy. A well-defined set of competencies is critical to ensure the preparedness and effectiveness of ambulance nurses in handling complex emergencies. This study aims to identify and validate these essential competencies using a modified Delphi methodology.

Method

To identify the fundamental competencies required for specialized ambulance nurses, we adopted a modified Delphi technique. ^{14 This method, known for its high level of agreement among involved experts, allowed us to precisely define the competencies necessary to excel in this highly specialized field. The expert panel identified 77 separate competencies divided into various competency areas.}

The 77 competencies identified by the panel were categorized into 6 key areas: clinical competencies, decision-making, communication, interpersonal skills, management, and leadership. This categorization was guided by the panel’s feedback and consensus. This high number of competencies reflects the complex and rigorous demands of the ambulance nursing profession, as unanimously evaluated by the experts.

This study used a modified Delphi method, which included the use of 2 separate expert panels (clinical and academic) and the customization of the questionnaire based on a preliminary review of relevant literature. These modifications were made to ensure a thorough exploration of competencies from both practical and theoretical perspectives.

Delphi Methodology

In this study, we focused on defining the variation of practice in assessing justified and unjustified needs and identifying the factors influencing the practice of emergency nurses in prehospital settings. Our research aims to examine the presence of variations in practice and need assessment by nurses working in ambulances, particularly in territorial emergencies. Ultimately, solutions will be developed to reduce unjustified prehospital practice variations. A Delphi survey was conducted between November 2022 and April 2023. The Delphi technique is a method used to reach a consensus among experts using multiple rounds of feedback collection to investigate and understand the variables affecting a specific problem, topic, or issue.

In this study, an online modified Delphi survey was used to collect the opinions of a group of experts through consensus, which was achieved after 2 rounds of the Delphi study, with a clear set of competencies identified through expert feedback in each round.

Consensus was reached after 2 rounds of the Delphi survey. In the first round, experts identified a broad set of competencies. In the second round, a threshold of 70% agreement was used to finalize the competencies, and results were analyzed to determine the areas of consensus and divergence. This was done to achieve a predetermined consensus level of 70% on the proposed definitions of justified and unjustified practice variations. Additionally, the expert panel was presented with aspects to evaluate whether and how certain practices might influence need assessment and the factors potentially impacting practical actions. Before the start of the Delphi survey, a literature review was conducted to find scientific papers describing the definitions of practice variation and the factors influencing it. During the Delphi survey's design, this review's results were used for both the definitions and the determined factors.

The Delphi Questionnaire

The expert panel was selected prior to the first round of the Delphi study. The questionnaire was developed based on a review of relevant literature and further refined through the responses collected during the first round. These definitions were presented in the first Delphi round, and subsequently, the questionnaire was divided into competency subgroups based on the responses collected during the exploratory phase. Concurrently, the study’s participant panel was selected. It consisted of a heterogeneous group of professionals, including university lecturers and clinical experts, to comprehensively represent diverse perspectives and experiences in the field.

The decision to involve 2 separate panels of clinical and academic experts was made to ensure a broad representation of perspectives. This distinction allowed us to explore both the practical application of competencies in clinical settings and the theoretical understanding of these competencies in educational environments.

The second questionnaire was designed to evaluate the level of agreement among experts regarding the competencies identified in the first questionnaire. Competency statements were presented in random order and assessed using a 3-point agreement scale.

Data Analysis

The responses were analyzed using IBM® SPSS® Statistics, version 26. Descriptive statistics were used to assess the levels of consensus among the experts.

Procedure And Participants

This Delphi study recruited a panel of experts for this study. The term “expert” refers to those who have demonstrable experience and/or knowledge of the topic under study, such as representatives of experienced nurses working in the extraterritorial emergency, university professors, and researchers otherwise involved in the territorial emergency. Email was used to contact any panel members in academic and emergency settings. Convenience sampling was used to choose panel participants who had shown interest in contributing to the study. Generally, a minimum of 10 panel participants is considered sufficient for a Delphi study based on the number of questions asked. However, a larger group of panelists can be more reliable and reduce the risk of errors. Therefore, to facilitate sampling, we invited 35 committee members for each round and would have expected a minimum of 30 members, but only 10 invitations were accepted. ¹⁵

The inclusion criteria for panel experts included a minimum of 10 years of experience in prehospital emergency nursing or academia, a recognized role in clinical leadership or education, and a demonstrated interest in advancing nursing practice through research or professional development.

Ethical Considerations

In accordance with the ethical standards governing scientific research, this study underwent ethical review and approval by the Company Ethics Review Committee (Protocol N.12.09.2021). Before participating, panel experts received detailed information regarding the study’s purpose and procedures. A specific section of the initial questionnaire was dedicated to data confidentiality and privacy, emphasizing the voluntary nature of participation and the right to withdraw from the study at any time without repercussions. Additionally, experts provided informed consent by submitting their written responses to the first questionnaire. Data confidentiality was maintained through various security measures. All collected information was stored on a secure server, accessible only to the authorized research team. The primary author of the study was the only individual privy to the identities of the panel experts. Although the responses to both questionnaires were recorded for potential follow-up, it was not possible to associate specific responses with individual participants. These precautions ensured adherence to fundamental ethical principles, including informed consent, data confidentiality, and the right to privacy for the experts involved in the study.

Panel Composition And Anonymity

To preserve anonymity and ensure the objectivity of responses, the identities of the panel experts were not revealed to each other. Additionally, the results were made independent of the participants’ professional backgrounds and personal relationships. Overall, the panel consisted of 10 strategically selected individuals, including specialized nurses with operational experience in prehospital emergency services and university lecturers with relevant academic expertise.

Data Collection

For data collection, we used web-based electronic questionnaires customized by the authors through Google Forms. Each panel member received an email link to access the active questionnaire, where they could anonymously express their opinions. The initial questionnaire asked experts to describe the desired competencies for ambulance nurses, divided into 6 competency areas. Subsequently, the responses were analyzed using qualitative content analysis, following Burnard’s (1991) methodology. ¹⁶

Results Sample Characteristics

The panel of experts consisted of 10 clinical and academic professionals, with a mean age of 53 and an average of 30 years of experience in prehospital emergency care.

The clinical expert sample consisted of 3 males and 2 females with a mean age of 55 years. Regarding professional experience, they averaged 30 years of service, with 60% holding a specialized or master’s degree, 20% holding a first-level master’s degree, and another 20% holding another type of degree. The academic expert sample was similar, comprising 3 males and 2 females with an average age of 52 years. They also averaged 30 years of service, with 80% holding a specialized or master’s degree, while 1 member held a second-level master’s degree.

Phase 1 Results - Clinical Experts

From the analysis and interpretation of responses provided by the clinical experts in the first questionnaire, 12 distinct domains were identified, encompassing a total of 31 competencies. In the context of competencies associated with professional values, the experts emphasized 2 key aspects: holistic abilities and ethical-deontological and legal competencies, recognizing their fundamental importance for nursing practice. Three core competencies were highlighted in defining the nurse's role: understanding patient needs, awareness of one’s role within the health care context, and professional responsibility in ensuring quality care. Five advanced competencies were identified in the domain of nursing practice, including competent airway management, accurate patient assessment, advanced ECG interpretation, and precise application of advanced protocols, showcasing the complexity and diversity of required competencies in clinical practice. The cognitive competencies domain revealed a wide range of abilities, with 8 distinct competencies, including deductive, organizational, comparative, critical thinking, proposal, health education, risk assessment, and behavioral competencies, underscoring the need for a robust cognitive foundation to tackle complex challenges in nursing care. Two key competencies emerged in the area of communication competencies: active listening and competence in public speaking techniques, which are essential for effective interaction with patients and other health care professionals. Interpersonal competencies were identified as fundamental for nurses, with particular emphasis on relational and empathetic abilities, crucial for creating an empathetic and patient-centered care environment.

Two specific competencies regarding communication technology competencies were identified: effective de-escalation and defusing techniques, highlighting the growing importance of digital competencies in contemporary nursing practice. In the management competencies domain, 2 key competencies were outlined: the ability to make effective decisions and solve problems efficiently, emphasizing the crucial role of nurses as leaders and managers in resource management and daily challenges. Finally, in the leadership competencies domain, the ability to manage the group was identified as the sole competency, underscoring the importance of leadership in promoting a collaborative and goal-oriented environment within nursing teams. In the final open item, the experts highlighted the importance of continuous education as a transversal competency essential for addressing evolving challenges in nursing practice and maintaining high standards of professionalism and competence.

Phase 2 Results - Clinical Experts

The statistical analysis of the second questionnaire data showed unanimous agreement among clinical experts on all 36 identified competencies ( ^Table 1 ). The clinical experts unanimously agreed on 16 fundamental competencies, confirming their relevance and robustness in the context of nursing practice. Among the unanimously agreed competencies were the ability to understand patient needs, awareness of one’s professional role, competency in patient clinical status assessment and application of evaluation scales, and effective management of advanced protocols. Similarly, decision-making, deductive, comparative, and risk assessment competencies, active listening, effective communication, interpersonal relationships, group management, and commitment to continuous education were confirmed. Additionally, on 14 other competencies, clinical experts reached 80% agreement, highlighting the importance of advanced airway management, ECG interpretation competencies, robust ethical-deontological and legal competencies, holistic, proposal, organizational, and critical decision-making competencies. These results confirm the extensive range of competencies required for ambulance nurses to provide quality care in complex and evolving situations. However, for 1 competency, decision-making, the group did not reach a unanimous agreement, with a consensus of 60%. This could indicate the complexity or varied interpretation of this competence in the specific context of out-of-hospital nursing care.

Phase 1 Results - Academic Experts

From the analysis and interpretation of the academic experts’ responses to the first questionnaire, 46 competencies were identified across various key domains of nursing practice. Among competencies associated with professional values, 3 were particularly highlighted: holistic ability, which encompasses a comprehensive and integrated view of patient care; spiritual abilities, implying sensitivity to the patient’s spiritual dimensions; and the ability to be objective and unbiased, fundamental for ensuring equitable and non-discriminatory treatment. In the domain of competencies associated with the nurse’s role, 3 key competencies emerged: ethical-deontological competencies, guiding professional action according to moral and ethical principles; educational competencies, essential for knowledge transfer to patients and health care staff; and relational competencies, facilitating the building of empathetic and trusting relationships with patients and colleagues. The domain of competencies associated with nursing practice identified 9 competencies in total. These include the ability to use new technologies and employ electromedical equipment, advanced invasive technique competencies, solid pharmacological knowledge, and applying advanced cardiopulmonary resuscitation (CPR) protocols and assessing patient clinical conditions. The decision-making domains include 6 fundamental competencies, such as anticipation, timely decision-making, and clinical risk assessment, which are crucial for providing prompt and appropriate nursing care. In the cognitive competencies domain, 7 key competencies were defined, including specialist competencies, mental flexibility, and the ability to make decisions and analyze clinical contexts, enabling nurses to adapt and respond effectively to complex and changing situations. Communication competencies identified include nonverbal communication, active listening, and metacommunication competencies, essential for effective communication with patients and the health care team. Five abilities were identified in the interpersonal competencies domain, including empathy, relational competencies, and management of aggressive behaviors, contributing to establishing positive and constructive relationships with patients and colleagues. Communication technology competencies include IT competencies, conflict and tension management abilities (de-escalation and defusing), and technological competencies, which are increasingly relevant in today’s digital health care context. Three competencies emerged in the leadership competencies domain: team management leadership and the ability to communicate effectively and humbly. Regarding management competencies, 2 main abilities were identified: the ability to apply problem-solving and the ability to evaluate and monitor care processes, which are fundamental for ensuring the effectiveness and quality of provided care. Finally, 3 competencies were highlighted in the group dynamics management competencies domain, including relational technical competencies, group dynamics management, and collaboration ability, which are fundamental for fostering a collaborative and productive atmosphere within the nursing team. Additionally, a new competency, self-control, emerged during the analysis, representing the ability to maintain control of one’s emotions and reactions in stressful or critical situations, emphasizing the importance of emotional management in nursing.

Phase 2 Results - Academic Experts

In the next phase of our study, we further examined the agreement expressed by academic experts on the identified competencies ( ^Table 2 ). Notably, the academic experts showed unanimous agreement, 100%, on 29 competencies. This total consensus suggests a strong convergence of opinions and a clear shared vision regarding the essential competencies of ambulance nurses. Among the unanimously agreed competencies were the ability to be objective and unbiased, fundamental for ensuring an impartial and professional approach to patients, and the competent use of new technologies and electromedical tools, reflecting the importance of updating and adopting innovative practices in emergency health care.

The breadth of competencies, ranging from managing cardiac emergencies to assessing clinical conditions, testifies to the complexity and vastness of responsibilities entrusted to specialized nurses in critical situations. In addition to the unanimously agreed competencies, 9 competencies achieved an 80% or higher agreement. These competencies include crucial aspects such as relational competencies, critical for establishing trust and collaboration with patients and colleagues, and advanced invasive technique competencies, demonstrating the need for thorough training and mastery of critical procedures in prehospital care.

Emotional support and empathy, expressed through nonverbal communication and active listening, represent fundamental pillars for ensuring patient-centered care and sensitivity to their emotional needs. Despite this broad consensus, there was an interesting debate on some specific competencies. Six competencies achieved a 60% agreement, suggesting a minority of academic experts with slightly divergent opinions on issues such as holistic competencies and ethical-deontological competencies. This scenario reflects the complexity and multidimensionality of competencies required for specialized nurses in ambulance settings, which can provoke debates and different interpretations regarding their priorities and relative importance in emergency health care.

Even more interesting were the 2 competencies for which no significant agreement was reached, with a 40% consensus: spiritual and educational competencies. This finding highlights the complexity and sensitivity of these topics, which can be interpreted differently from various cultural and personal perspectives. Further exploration of these themes through more in-depth discussions and qualitative analyzes could be fascinating to understand better the differences in opinion and the motivations behind them.

In conclusion, the analysis of the agreement expressed by academic experts on the identified competencies provided a detailed overview of the areas of convergence and divergence in emergency health care. These results form a solid foundation for developing targeted training programs and practical guidelines, enabling specialized nurses to be adequately prepared to face the complex and dynamic challenges of prehospital care. To streamline the manuscript, the tables illustrating the consensus results are available in the supplementary materials.

The convergence and divergence of opinions between these 2 groups of experts highlight both challenges and opportunities in identifying and developing competencies in this field ( ^Table 3 ).

Through a synthesis of historical perspectives and contemporary research findings, this convergence highlights the enduring significance of technical proficiency and relational competence in shaping nursing practice and ensuring positive patient outcomes ( ^Table 4 ).

Discussion

This study presents novel findings regarding the essential competencies required for ambulance nurses in Italy. The expert panel identified a comprehensive set of competencies across 6 domains, with particular emphasis on advanced clinical decision-making and interpersonal skills. These findings have important implications for nursing education and the development of targeted training programs for ambulance nurses. The analysis of data collected through the Delphi questionnaire cycles provided a detailed and multifaceted overview of the competencies deemed essential by clinical and academic experts for specialized ambulance nurses.

Both clinical and academic experts demonstrated substantial concurrence regarding a core set of competencies, emphasizing their criticality within the realm of emergency nursing. The unanimous recognition of competencies such as the ability to comprehend patient needs, a deep understanding of one’s professional responsibilities, and adeptness in managing advanced protocols underscores their foundational significance in nursing practice. This consensus reflects a collective understanding of nursing’s essence, where a harmonious blend of technical proficiency and interpersonal acumen is imperative for delivering superior patient care. ^{17 , 18}

Moreover, recent research has reaffirmed the pivotal role of these competencies in emergency nursing. For instance, a study by Kwame and Petrucka ^{19 found that nurses with a strong understanding of patient need and a clear awareness of their professional role were better equipped to navigate complex clinical scenarios and deliver patient-centered care effectively. Similarly, research by Strandås et al 13 highlighted the importance of competent protocol management in ensuring timely and appropriate interventions, ultimately enhancing patient outcomes. These contemporary studies provide empirical support for the consensus reached by clinical and academic experts, further validating the significance of these competencies in emergency nursing practice. 13 , 19}

Furthermore, the alignment between clinical and academic perspectives on these competencies underscores their universal relevance across different contexts and settings within the nursing profession. Whether in clinical practice or academia, nurses must possess a common foundation of competencies and knowledge to fulfill their roles effectively and contribute to optimal patient care outcomes. ^{20 This convergence serves as a testament to the cohesive vision shared by stakeholders across the nursing spectrum, emphasizing the fundamental principles that underpin nursing practice irrespective of the specific domain or context. 21}

In summary, the consensus among clinical and academic experts regarding key competencies in emergency nursing reaffirms their foundational importance in delivering high-quality patient care.

Despite the overarching consensus reached by experts, notable disparities emerged concerning certain competencies, notably those pertaining to holistic and spiritual dimensions. The divergence in viewpoints on these areas may be attributed to diverse personal values, professional backgrounds, and cultural orientations among the participants. For instance, while technical and practical competencies garnered widespread concurrence, spiritual competencies exhibited a lower level of consensus, with only 40% agreement among academics. ^{14 This discrepancy suggests a potential discrepancy in the prioritization of these aspects within the nursing profession, warranting further investigation.}

The observed variation underscores the complexity of integrating holistic and spiritual dimensions into nursing education and practice. While integral to providing comprehensive patient care, these competencies may need to be revised in terms of definition, measurement, and implementation. Consequently, there is a pressing need for in-depth qualitative research to elucidate the underlying factors contributing to these differences and devise strategies for their effective integration into nursing curricula.

Recent studies have shed light on the significance of addressing holistic and spiritual dimensions in nursing education and practice. For instance, research by Duran et al ^{22 emphasized the role of spirituality in promoting resilience and coping mechanisms among both patients and health care professionals, thereby enhancing overall well-being. Similarly, a study by Scott Barss 23 highlighted the importance of incorporating holistic care principles into nursing education to foster a more patient-centered approach to care delivery. These findings underscore the relevance of holistic and spiritual competencies in contemporary nursing practice and provide the impetus for further exploration and integration within educational frameworks. 22 , 23}

In conclusion, while consensus was achieved on many competencies, the discordance regarding holistic and spiritual dimensions highlights the need for continued research and reflection within the nursing community. By addressing these disparities through qualitative inquiry and fostering dialogue among stakeholders, the nursing profession can strive toward a more comprehensive and patient-centric approach to care delivery.

The significance of continuing education emerged as a prominent theme in the analysis, reflecting the dynamic nature of health care and the imperative for nurses to stay abreast of evolving clinical practices and technologies. Experts underscored the crucial role of ongoing learning in ensuring that nurses maintain high standards of competence and remain adaptable in the face of emerging challenges. ^{15 This emphasis on continuous professional development aligns with the broader ethos of lifelong learning within the nursing profession, wherein practitioners are encouraged to engage in reflective practice and pursue opportunities for skill enhancement and knowledge acquisition. 24}

In the realm of emergency nursing, where situations are inherently unpredictable and demand rapid and effective responses, the importance of continuing education is particularly salient. The dynamic nature of emergencies necessitates that nurses possess a solid foundation of core competencies and the agility to adapt to evolving circumstances and leverage the latest evidence-based practices. ^{25 Nurses can enhance their resilience and capacity to navigate complex clinical scenarios with confidence and competence by engaging in ongoing education and professional development initiatives.}

Recent literature underscores the critical role of continuing education in emergency nursing practice. Research by Huang and Wang ^{26 highlighted the benefits of simulation-based training programs in preparing nurses for high-stress emergencies, emphasizing the importance of experiential learning in skill acquisition and retention. Similarly, a study by Bendowska and Baum 27 emphasized the role of interdisciplinary education in promoting collaboration and teamwork among health care providers in emergency settings. These findings underscore continuing education's multifaceted benefits in enhancing individual competence and team effectiveness in emergency nursing contexts. 26 , 27}

In conclusion, the emphasis on continuing education as a means to maintain competence, cultivate resilience, and adapt to the dynamic demands of emergency nursing reflects a fundamental tenet of professional practice. By investing in ongoing learning opportunities and embracing a mindset of continuous improvement, nurses can optimize their capacity to deliver high-quality care and effectively respond to the evolving needs of patients in emergency settings.

The findings of this study lay a robust groundwork for the development of tailored training programs aimed at enhancing the competency of ambulance nurses in specialized emergency care settings. The identified competencies serve as a comprehensive framework that can inform the design of curricula tailored to address the multifaceted challenges inherent in advanced clinical practice. ^{14 By aligning training initiatives with the identified competencies, educators can ensure that nurses have the requisite knowledge, competencies, and abilities to navigate the complexities of prehospital emergency care with confidence and proficiency.}

A key takeaway from the study is the importance of integrating communicative and interpersonal competencies into training programs alongside technical competencies. While technical proficiency is undoubtedly crucial in emergency nursing practice, effective communication and interpersonal abilities are equally indispensable for delivering patient-centered care and fostering collaborative relationships within multidisciplinary health care teams. ^{5 By prioritizing the development of these competencies within training curricula, educators can equip nurses with the interpersonal competencies and communication strategies needed to engage effectively with patients, families, and colleagues in high-stakes emergencies.}

Recent research underscores the value of integrating communication and interpersonal competencies into nursing education curricula. Studies by Alsabri et al ^{28 emphasize the pivotal role of effective communication in promoting patient safety and enhancing clinical outcomes in emergency care settings. Similarly, research by Alsulamy et al 29 highlights the importance of interpersonal competencies in building rapport with patients and facilitating collaborative decision-making processes. These findings underscore the critical importance of incorporating communicative and interpersonal competencies into training programs to prepare nurses for the complex realities of emergency nursing practice. 28 , 29}

In summary, the emphasis on integrating communicative and interpersonal competencies into training programs represents a strategic approach to preparing nurses for the challenges of advanced clinical practice in prehospital emergency care settings. By fostering the development of these essential competencies alongside technical proficiencies, educators can empower nurses to deliver high-quality, patient-centered care and effectively collaborate with colleagues to optimize patient outcomes in emergencies.

Limitations

It is essential to acknowledge the potential impact of the limited expert sample on the study’s findings. While the Delphi method is renowned for its ability to facilitate consensus among experts, the representativeness of the sample is a crucial consideration that warrants attention. The composition of the expert panel, comprising individuals with diverse clinical and academic backgrounds, undoubtedly enriches the breadth of perspectives and insights brought to the forefront. However, the relatively small size of the sample may limit the generalizability of the results and the extent to which they accurately reflect the broader population of ambulance nurses.

Future research endeavors in this domain would greatly benefit from a more extensive and diverse sample of experts, encompassing a broader spectrum of clinical specialties, academic disciplines, and geographic regions. By expanding the scope of participant recruitment, researchers can enhance the robustness and validity of their findings, ensuring that they capture a more comprehensive array of perspectives and experiences within the field of emergency nursing. Additionally, efforts to recruit experts representing diverse demographic characteristics, such as age, gender, and years of professional experience, can further enrich the depth and breadth of insights gleaned from the Delphi process.

Moreover, the inclusion of experts from interdisciplinary fields related to emergency care, such as emergency medicine, paramedicine, and public health, could offer valuable interdisciplinary perspectives on ambulance nursing competencies. Collaborative engagement with stakeholders from diverse professional backgrounds can foster a more holistic understanding of prehospital emergency care's multifaceted challenges and complexities, thereby informing more nuanced and contextually relevant competency frameworks.

Implications for Emergency Nurses

The competencies identified in this study have significant practical implications for the training and practice of specialized prehospital emergency nurses. Firstly, nursing education programs should be updated to include specific modules addressing the advanced competencies necessary for rapidly assessing patients’ clinical status, stabilizing critical medical conditions, managing trauma, and applying advanced resuscitation protocols. Furthermore, training should emphasize the development of communication and interpersonal competencies, which are crucial for effective collaboration with multidisciplinary team members and for managing relationships with patients and their families in high-pressure situations. Health care institutions should implement continuous education programs and realistic simulations to ensure that nurses remain current with the latest technologies and clinical practices. Finally, organizational policies should support nurses’ adaptability and resilience by providing adequate resources and safe working environments, enabling them to tackle the dynamic challenges of prehospital emergency care effectively. By adopting these measures, the quality of care provided can be significantly improved, consequently enhancing patient outcomes.

Conclusions

This study identified crucial competencies for specialized ambulance nurses, noting both consensus and dissent between clinical and academic experts. Key competencies include advanced clinical skills, decision-making, communication, and management abilities, highlighting the multifaceted nature of ambulance nursing. Consensus on many competencies, such as rapid patient assessment and effective communication, underscores their importance for high-quality emergency care.

These core competencies are crucial for patient safety and positive outcomes in high-stress environments. Divergences, such as the importance of holistic and spiritual competencies, suggest a need for balanced training programs that address both technical proficiency and comprehensive patient care. The findings provide a basis for developing targeted training programs tailored to emergency health care demands. Incorporating these competencies into curricula will prepare nurses to meet ambulance nursing challenges, including informed decision-making, stress management, and effective communication. Continuous education and professional development are vital, especially with rapid advancements in medical technology. Health care institutions should promote lifelong learning, encouraging nurses to update their competencies regularly.

Author Disclosures

Conflicts of interest: There are no conflicts of interest

This research was funded by the Center of Excellence for Nursing Scholarship of the Order of Nursing Professions in Rome (OPI Rome).

Supplementary Data

Application

Table 1

Level of importance for final competency statements of clinical expert

Clinical expert
		N	%
1. In your opinion, in the domain of competencies associated with professional values, which are among these that the nurse who works in an ambulance must necessarily possess? [Holistic competencies]
Good	1. Fully agree	2	40.0
	2. Agree	3	60.0
1. In your opinion, in the domain of competencies associated with professional values, which are among these that the nurse who works in an ambulance must necessarily possess? [Spiritual Competencies]
Good	2. Agree	2	40.0
	3. Neither agree nor disagree	1	20.0
	4. Disagree	1	20.0
	5. Not at all agree	1	20.0
1. In your opinion, in the domain of competencies associated with professional values, which are among these that the nurse who works in an ambulance must necessarily possess? [Ability to be objective and without prejudice]
Good	1. Fully agree	5	100.0
2. In your opinion, within the domain of competencies associated with the role of the nurse, which are among these those that the nurse who works in an ambulance must necessarily possess? [Ethical-deontological competencies]
Good	1. Fully agree	3	60.0
	2. Agree	2	40.0
2. In your opinion, within the domain of competencies associated with the role of the nurse, which are among these those that the nurse who works in an ambulance must necessarily possess? [Educational Competencies]
Good	1. Fully agree	2	40.0
	2. Agree	1	20.0
	3. Neither agree nor disagree	2	40.0
2. In your opinion, within the domain of competencies associated with the role of the nurse, which are among these those that the nurse who works in an ambulance must necessarily possess? [Relational Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to use new technologies]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to use electromedical equipment]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Advanced Competencies in Invasive Techniques]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Pharmacological Expertise]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Acquisition of competencies in basic BLSD, PBLSD and advanced PTC and PHTC courses]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to use new technologies]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Knowledge of CPR protocols]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Knowledge and Application of Rating Scales]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Application of Advanced CPR Protocols]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Clinical Condition Assessment Capacity]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Ability to anticipate]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Decision-making ability]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Ability to act promptly]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Communication Competencies]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Clinical Condition Assessment Capacity]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Clinical Risk Assessment Capacity]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Specialist expertise]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Mental elasticity]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Ability to compare]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Capacity to respect human dignity]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Application of Problem Solving,]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Decision Making Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Ability to Analyze Clinical Contexts]
Good	1. Fully agree	5	100.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Nonverbal Communication Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Listening Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Competencies in the application of metacommunication]
Good	1. Fully agree	3	60.0
	2. Agree	2	40.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Communication Competencies]
Good	1. Fully agree	5	100.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Empathic Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Relational Competencies]
Good	1. Fully agree	3	60.0
	2. Agree	2	40.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Team Management Competencies]
Good	1. Fully agree	5	100.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Observation Competencies]
Good	1. Fully agree	5	100.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Ability to handle aggressive behavior]
Good	1. Fully agree	5	100.0
8. In your opinion, which of these communication technology competencies are fundamental for the ambulance nurse? [Computer Competencies]
Good	1. Fully agree	3	60.0
	2. Agree	2	40.0
8. In your opinion, which of these communication technology competencies are fundamental for the ambulance nurse? [Conflict De-escalation Capability]
Good	1. Fully agree	5	100.0
8. In your opinion, which of these communication technology competencies are fundamental for the ambulance nurse? [Debriefing & Defusing Competencies]
Good	1. Fully agree	5	100.0
8. In your opinion, which of these communication technology competencies are fundamental for the ambulance nurse? [Technology Competencies]
Good	1. Fully agree	5	100.0
9. In your opinion, among these leadership competencies, the nurse who works in an ambulance must necessarily possess? [Team Management Leadership]
Good	1. Fully agree	5	100.0
9. In your opinion, among these leadership competencies, the nurse who works in an ambulance must necessarily possess? [Communication Competencies]
Good	1. Fully agree	5	100.0
9. In your opinion, among these leadership competencies, the nurse who works in an ambulance must necessarily possess? [Be humble]
Good	1. Fully agree	3	60.0
	2. Agree	1	20.0
	3. Neither agree nor disagree	1	20.0
10. In your opinion, among these management competencies, the nurse who works in an ambulance must necessarily possess? [Problem-solving competencies]
Good	1. Fully agree	5	100.0
10. In your opinion, among these management competencies, the nurse who works in an ambulance must necessarily possess? [Ability to verify and evaluate care processes]
Good	1. Fully agree	5	100.0
11. In your opinion, among these competencies in managing group dynamics, the nurse who works in an ambulance must necessarily possess? [Technical/interpersonal competencies]
Good	1. Fully agree	5	100.0
11. In your opinion, among these competencies in managing group dynamics, the nurse who works in an ambulance must necessarily possess? [Competencies in managing group dynamics]
Good	1. Fully agree	5	100.0
11. In your opinion, among these competencies in managing group dynamics, the nurse who works in an ambulance must necessarily possess? [Group Collaboration Competencies]
Good	1. Fully agree	5	100.0
12. Which of these specific competencies not highlighted in the areas described above, do you consider that the nurse who works in an ambulance should necessarily possess [Self-control]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
	Total	5	100.0

Table 2

Level of importance for final competency statements of academic expert

Academic expert
1. In your opinion, in the domain of competencies associated with professional values, which are among these that the nurse who works in an ambulance must necessarily possess? [Holistic Capabilities]
		N	%
Good	1. Fully agree	4	80.0
	3. Neither agree nor disagree	1	20.0
1. In your opinion, in the domain of competencies associated with professional values, which are among these that the nurse who works in an ambulance must necessarily possess? [Ethical-deontological and legal competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
2. In your opinion, within the domain of competencies associated with the role of the nurse, which are among these those that the nurse who works in an ambulance must necessarily possess? [Comprehension Competencies]
Good	1. Fully agree	5	100.0
2. In your opinion, within the domain of competencies associated with the role of the nurse, which are among these those that the nurse who works in an ambulance must necessarily possess? [Role Awareness]
Good	1. Fully agree	5	100.0
2. In your opinion, within the domain of competencies associated with the role of the nurse, which are among these those that the nurse who works in an ambulance must necessarily possess? [Professional Liability]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Advanced Airway Management Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Competencies in assessing the patient’s clinical status]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Advanced ECG Interpretation Competencies]
Good	1. Fully agree	4	80.0
	3. Neither agree nor disagree	1	20.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to make a correct assessment of the patient’s clinical status]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Proficiency in the correct application of rating scales]
Good	1. Fully agree	5	100.0
3. In your opinion, what are the competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Proficiency in the correct application of advanced protocols]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Decision-making ability]
Good	1. Fully agree	5	100.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Ethical-deontological and legal competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Holistic Capabilities]
Good	1. Fully agree	4	80.0
	3. Neither agree nor disagree	1	20.0
4. In your opinion, what are the competencies associated with clinical decision-making that it is essential for the nurse operating in an ambulance to possess? [Propositional capacity]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Deductive Competencies]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Organizational Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Comparison Competencies]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Critical Thinking Processing]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Proactive Ability]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Health Education Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Risk Assessment Competencies]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Advanced Competencies]
Good	1. Fully agree	5	100.0
5. In your opinion, which of these cognitive competencies should an ambulance nurse possess? [Behavioral Competencies]
Good	1. Fully agree	5	100.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Listening Competencies]
Good	1. Fully agree	5	100.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Communication Competencies]
Good	1. Fully agree	5	100.0
6. In your opinion, which of these communication competencies are fundamental for the nurse who works in an ambulance? [Ability to apply public speaking]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Interpersonal Competencies]
Good	1. Fully agree	5	100.0
7. In your opinion, which of these interpersonal competencies are fundamental for the nurse who works in an ambulance? [Empathic Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
8. In your opinion, which of these communication technology competencies are fundamental for the ambulance nurse? [Ability to apply the D-Escalation technique]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
8. In your opinion, which of these communication technology competencies are fundamental for the ambulance nurse? [Knowing how to apply defusing]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
9. In your opinion, among these leadership competencies, the nurse who works in an ambulance must necessarily possess? [Group Management Competencies]
Good	1. Fully agree	5	100.0
10. In your opinion, among these management competencies, the nurse who works in an ambulance must necessarily possess? [Implementing Decision Making]
Good	1. Fully agree	3	60.0
	2. Agree	2	40.0
10. In your opinion, among these management competencies, the nurse who works in an ambulance must necessarily possess? [Implement Problem Solving]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
11. In your opinion, among these competencies in managing group dynamics, the nurse who works in an ambulance must necessarily possess? [Communication Competencies]
Good	1. Fully agree	5	100.0
11. In your opinion, among these competencies in managing group dynamics, the nurse who works in an ambulance must necessarily possess? [Educational and Training Competencies]
Good	1. Fully agree	4	80.0
	2. Agree	1	20.0
12. Which of these specific competencies not highlighted in the areas described above, do you consider that the nurse working in an ambulance should necessarily possess [Continuing Education]
Good	1. Fully agree	5	100.0

Table 3

Mean level of importance for final competency statements of clinical expert

Domain	Statement numbers	Competence statement clinical expert	Mean	SD
Domain of Competencies associated with professional values	1.1	In your opinion. in the domain of competencies associated with professional values. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Holistic Competencies]	1.60	0.548
	1.2	In your opinion. in the domain of competencies associated with professional values. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Spiritual Competencies]	3.20	1.304
	1.3	In your opinion. in the domain of competencies associated with professional values. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Ability to be Objective and Without Prejudice]	1.00	0.000
Domain of Competencies associated with the nurse role	2.1	In your opinion. in the domain of competencies associated with the role of the nurse. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Ethical-Deontological Competencies]	1.40	0.548
	2.2	In your opinion. in the domain of competencies associated with the role of the nurse. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Educational Competencies]	2.00	1.000
	2.3	In your opinion. in the domain of competencies associated with the role of the nurse. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Relational Competencies]	1.20	0.447
Domain of Competencies associated with nursing practice	3.1	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to Use New Technologies]	1.00	0.000
	3.2	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to Use Electromedical Equipment]	1.00	0.000
	3.3	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Advanced Competencies in Invasive Techniques]	1.20	0.447
	3.4	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Pharmacological Expertise]	1.00	0.000
	3.5	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Acquisition of Competencies in Basic BLSD. PBLSD and Advanced PTC and PHTC Courses]	1.00	0.000
	3.6	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to Use New Technologies]	1.00	0.000
	3.7	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Knowledge of CPR protocols]	1.00	0.000
	3.8	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Knowledge and Application of Rating Scales]	1.00	0.000
	3.9	In your opinion. what are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Application of Advanced CPR protocols]	1.00	0.000
	3.10	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Clinical Condition Assessment Capacity]	1.00	0.000
Domain of Competencies associated with clinical decision-making:	4.1	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Ability to Anticipate]	1.00	0.000
	4.2	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Decision-Making Ability]	1.00	0.000
	4.3	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Ability to Act Promptly]	1.00	0.000
	4.4	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Communication Competencies]	1.00	0.000
	4.5	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Clinical Condition Assessment Capacity]	1.00	0.000
	4.6	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Clinical Risk Assessment Capacity]	1.00	0.000
Cognitive Competencies Domain	5.1	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Specialist Expertise]	1.20	0.447
	5.2	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Mental Elasticity]	1.00	0.000
	5.3	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Ability to Compare]	1.20	0.447
	5.4	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Capacity to Respect Human Dignity]	1.00	0.000
	5.5	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Application of Problem Solving]	1.00	0.000
	5.6	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Decision Making Competencies]	1.20	0.447
	5.7	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Ability to Analyze Clinical Contexts]	1.00	0.000
Domain of Communication Competencies	6.1	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Nonverbal Communication Competencies]	1.20	0.447
	6.2	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Listening Competencies]	1.20	0.447
	6.3	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Competencies in the Application of Metacommunication]	1.40	0.548
	6.4	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Communication Competencies]	1.00	0.000
Interpersonal Competencies Domain	7.1	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Empathic Competencies]	1.20	0.447
	7.2	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Relational Competencies]	1.40	0.548
	7.3	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Team Management Competencies]	1.00	0.000
	7.4	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Observation Competencies]	1.00	0.000
	7.5	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Ability to Handle Aggressive Behavior]	1.00	0.000
Communication Technology Competencies Domain	8.1	In your opinion. Which of these communication technology Competencies are fundamental for the ambulance nurse? [Computer Competencies]	1.40	0.548
	8.2	In your opinion. Which of these communication technology Competencies are fundamental for the ambulance nurse? [Conflict De-Escalation Capability]	1.00	0.000
	8.3	In your opinion. Which of these communication technology Competencies are fundamental for the ambulance nurse? [Debriefing and Defusing Competencies]	1.00	0.000
	8.4	In your opinion. Which of these communication technology Competencies are fundamental for the ambulance nurse? [Technology Competencies]	1.00	0.000
Leadership Competencies Domain	9.1	In your opinion. among these leadership Competencies the nurse who works in an ambulance must necessarily possess? [Team Management Leadership]	1.00	0.000
	9.2	In your opinion. among these leadership Competencies. the nurse who works in an ambulance must necessarily possess? [Communication Competencies]	1.00	0.000
	9.3	In your opinion. among these leadership Competencies. the nurse who works in an ambulance must necessarily possess? [Be Humble]	1.60	0.894
Domain of management Competencies	10.1	In your opinion. among these management Competencies. the nurse who works in an ambulance must necessarily possess? [Problem-Solving Competencies]	1.00	0.000
	10.2	In your opinion. among these management Competencies. the nurse who works in an ambulance must necessarily possess? [Ability to Verify and Evaluate Care Processes]	1.00	0.000
Domain of group dynamics management Competencies	11.1	In your opinion. among these Competencies in managing group dynamics. the nurse who works in an ambulance must necessarily possess? [Technical/Interpersonal Competencies]	1.00	0.000
	11.2	In your opinion. among these Competencies in managing group dynamics. the nurse who works in an ambulance must necessarily possess? [Competencies in Managing Group Dynamics]	1.00	0.000
	11.3	In your opinion. among these Competencies in managing group dynamics. the nurse who works in an ambulance must necessarily possess? [Group Collaboration Competencies]	1.00	0.000
Self-control	12.1	Which of these specific Competencies not highlighted in the areas described above. do you believe that the nurse who works in an ambulance should necessarily possess [Self-Control]	1.20	0.447

Table 4

Mean level of importance for final competency statements of academic expert

Domain	Statement numbers	Competence statement academic expert	Mean	SD
Competencies associated with professional values	1.1	In your opinion. in the domain of competencies associated with professional values. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Holistic Capabilities]	1.40	0.894
	1.2	In your opinion. in the domain of competencies associated with professional values. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Ethical-Deontological and Legal Competencies]	1.20	0.447
Competencies associated with the role of the nurse practitioner	2.1	In your opinion. in the domain of competencies associated with the role of the nurse. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Comprehension Competencies]	1.00	0.000
	2.2	In your opinion. in the domain of competencies associated with the role of the nurse. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Role Awareness]	1.00	0.000
	2.3	In your opinion. in the domain of competencies associated with the role of the nurse. Which are among these those that the nurse who works in an ambulance must necessarily possess? [Professional Liability]	1.00	0.000
Competencies associated with nursing practice	3.1	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Advanced Airway Management Competencies]	1.20	0.447
	3.2	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Competencies in Assessing the Patient's Clinical Status]	1.00	0.000
	3.3	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Advanced ECG Interpretation Competencies]	1.40	0.894
	3.4	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Ability to Make a Correct Assessment of the Patient's Clinical Status]	1.00	0.000
	3.5	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Proficiency in the Correct Application of Rating Scales]	1.00	0.000
	3.6	In your opinion. What are the Competencies associated with nursing practice that it is essential for the nurse who works in an ambulance to possess? [Proficiency in the Correct Application of Advanced Protocols]	1.00	0.000
Competencies associated with clinical decision-making	4.1	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Decision-Making Ability]	1.00	0.000
	4.2	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Ethical-Deontological and Legal Competencies]	1.20	0.447
	4.3	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Holistic Capabilities]	1.40	0.894
	4.4	In your opinion. What are the Competencies associated with clinical decision-making that it is essential for the ambulance nurse to possess? [Propositional Capacity]	1.20	0.447
Cognitive Competencies	5.1	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Deductive Competencies]	1.00	0.000
	5.2	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Organizational Competencies]	1.20	0.447
	5.3	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Comparison Competencies]	1.00	0.000
	5.4	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Critical Thinking Processing]	1.40	0.548
	5.5	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Proactive Ability]	1.20	0.447
	5.6	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Health Education Competencies]	1.20	0.447
	5.7	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Risk Assessment Competencies]	1.00	0.000
	5.8	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Advanced Competencies]	1.00	0.000
	5.9	In your opinion. Which of these cognitive Competencies should an ambulance nurse possess? [Behavioral Competencies]	1.00	0.000
Communication and interpersonal Competencies	6.1	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Listening Competencies]	1.00	0.000
	6.2	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Communication Competencies]	1.00	0.000
	6.3	In your opinion. Which of these communication Competencies are fundamental for the nurse who works in an ambulance? [Ability to Apply Public Speaking]	1.20	0.447
	6.4	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Interpersonal Competencies]	1.00	0.000
	6.5	In your opinion. Which of these interpersonal Competencies are fundamental for the nurse who works in the ambulance? [Empathic Competencies]	1.20	0.447
	6.6	In your opinion. Which of these communication technology Competencies are fundamental for the ambulance nurse? [Ability to Apply the D-Escalation Technique]	1.20	0.447
	6.7	In your opinion. Which of these communication technology Competencies are fundamental for the ambulance nurse? [Knowing how to apply defusing]	1.20	0.447
Leadership and management Competencies	7.1	In your opinion. among these leadership Competencies. the nurse who works in an ambulance must necessarily possess? [Group Management Competencies]	1.00	0.000
	7.2	In your opinion. among these management Competencies. the nurse who works in an ambulance must necessarily possess? [Implementing Decision Making]	1.40	0.548
	7.3	In your opinion. among these management Competencies. the nurse who works in an ambulance must necessarily possess? [Implement Problem Solving]	1.20	0.447
	7.4	In your opinion. among these Competencies in managing group dynamics. the nurse who works in an ambulance must necessarily possess? [Communication Competencies]	1.00	0.000
	7.5	In your opinion. among these Competencies in managing group dynamics. the nurse who works in an ambulance must necessarily possess? [Educational and Training Competencies]	1.20	0.447
Continuing education	8.1	Which of these specific Competencies not highlighted in the areas described above. do you believe that the nurse who works in an ambulance should necessarily possess [Continuing Education]	1.00	0.000