Nursing Competencies in Helicopter Emergency Medical Services (HEMS) in Spain: A Qualitative Study of Professional Profiles and Advanced Training

ABSTRACT

Aim(s)

To explore how HEMS professionals perceive the role, competencies, training and professional development of nursing within aeromedical transport services in Spain, incorporating the perspectives of different professional profiles involved in HEMS operations.

Design

An interpretative qualitative study using phenomenologically informed thematic analysis.

Methods

Semi‐structured, in‐depth interviews were conducted and analysed using phenomenologically informed thematic analysis. Data were systematically coded through open coding and organised into themes and subthemes using ATLAS.ti.

Data Sources

Primary qualitative data were obtained from 17 purposively selected HEMS professionals through individual interviews. Interviews lasted 45–60 min, were audio‐recorded and transcribed verbatim.

Results

Four main categories emerged from the analysis: (1) access to the HEMS environment; (2) technical skills and competencies; (3) professional perspective and role development; and (4) structured professionalisation of the HEMS profile. Participants perceived that extensive prior experience in critical care settings, specialised academic training, supervised practice and advanced clinical simulation were necessary. Fully online training was widely perceived as insufficient. Participants identified core competencies, including advanced technical skills, knowledge of aerophysiology, aviation safety training, Crew Resource Management and Helicopter Underwater Escape Training. In addition, participants identified emotional resilience and physical fitness as personal attributes relevant to HEMS practice.

Conclusion

According to participants, HEMS nursing in Spain was described as a complex and highly specialised professional profile, characterised by extensive critical‐care experience, advanced technical competencies and structured, practice‐oriented training. The absence of a formalised training pathway contrasts with international standards and points to a perceived need for greater professional recognition and standardisation of competencies to support safe and high‐quality care.

Implications for the Profession and/or Patient Care

The findings provide qualitative evidence that may inform the future development of structured training pathways, competency frameworks and professional recognition for HEMS nurses in Spain. The findings may also inform future research on standardised education, advanced simulation and aviation safety training. Further research is needed to determine whether these educational approaches improve clinical decision‐making, patient safety and operational effectiveness in aeromedical transport.

Impact

The findings highlight the lack of a clearly defined and standardised competency framework and training pathway for HEMS nursing professionals in Spain. Participants perceived effective HEMS practice as requiring extensive prior critical‐care experience, advanced technical competencies, supervised practical training and specific personal attributes, including emotional resilience and physical preparedness. These findings are relevant to HEMS nurses, educators, policymakers and healthcare managers involved in aeromedical services in Spain and may also contribute to international discussions on advanced nursing practice in air medical transport.

Reporting Method

This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Patient or Public Contribution

No Patient or Public Contribution.

1. Introduction

On a global scale, 81.1% of cases attended by helicopter emergency medical services (HEMS) correspond to primary response operations aimed at providing emergency care at the scene of the incident, with trauma and acute cardiovascular conditions constituting the most frequent presentations. The remaining 18.9% of interventions correspond to inter‐hospital transfers (SEMICYUC 2019).

In Spain, scientific societies involved in emergency care, such as the Spanish Society of Emergency Medicine (SEMES) and the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC), recognise HEMS as an essential resource within the chain of care for critically ill patients (SEMICYUC 2019; SEMES 2020). This modality of transport requires not only specific logistical arrangements but also a highly specialised professional profile, characterised by advanced competencies in pre‐hospital care, robust decision‐making capacity in highly complex environments and effective multidisciplinary coordination skills (Vazquez Lima and Álvarez Rodríguez 2008). The role of healthcare personnel comprising HEMS teams is therefore critical to ensuring timely and effective care, particularly in hard‐to‐reach areas or in emergency situations requiring immediate intervention (Artero‐García et al. 2025).

Internationally, inter‐hospital transfers account for 18.9% of HEMS interventions, most frequently involving patients with cardiovascular, respiratory, or trauma‐related conditions (Lubillo Montenegro et al. 1997; Carchietti et al. 2011). The demand for this transport modality, particularly among critically ill patients, has increased steadily in recent years. When local therapeutic resources are insufficient for complex procedures, or when specialised care is required, inter‐hospital transfer constitutes the recommended strategy to ensure access to the most appropriate level of treatment. To achieve optimal clinical outcomes, such transfers should be performed during the early stages of disease progression or injury, while maintaining rigorous standards of care throughout the process (Nozawa et al. 2020; Sánchez and Galo 2015; Lanzarot Moreno et al. 2008).

Within the HEMS context, healthcare delivery constitutes a critical phase of the care continuum, in which both the initial clinical decisions and the patient's perceived experience of care depend, to a considerable extent, on the actions of the on‐board healthcare team (Artero García et al. 2025; Peng and Su 2022; Ringburg et al. 2009). Nursing professionals play a fundamental role that extends beyond purely technical care, encompassing comprehensive patient assessment, effective communication, emotional‐state management and rapid decision‐making under adverse conditions (Kawai et al. 2022; Slagt et al. 2022; Eaton et al. 2018). Achieving this requires distinct competencies, together with a level of training and clinical experience appropriately aligned with the demands of the aeromedical context (Mortazavi et al. 2003; Sierra and Serrano 2022; Broman et al. 2015).

The alignment of professional profiles and the periodic assessment of competencies are considered relevant to supporting patient safety and the effectiveness of medical transport. Currently, Spain lacks a mandatory, formal training programme for HEMS practice. The entry into force of Royal Decree 610/2024, which establishes the Specialty of Emergency Medicine, constitutes a preliminary step towards the development of such training (Artero García et al. 2025). By contrast, several international nursing organisations, including the New Zealand Flight Nurses Association, the American Flight Nurses Association and the UK Royal College of Nursing, have already established defined standards of care, offering HEMS crews dedicated training and clinical guidelines for the management of critically ill patients (Harding et al. 2013).

This study aims to explore the perspectives of HEMS professionals regarding the role, competencies, training and professional development of nursing within aeromedical transport services in Spain, incorporating the views of different professional profiles to provide a comprehensive understanding of HEMS nursing practice.

2. Methods

An interpretative qualitative approach was adopted, using phenomenologically informed thematic analysis to explore how HEMS professionals understood their roles, competencies and training experiences. The analysis examined the meanings participants attributed to their experiences while identifying patterns across the dataset through a systematic, cross‐case thematic approach (Tindall et al. 2009). The study was not designed as Interpretative Phenomenological Analysis (IPA); rather, thematic sufficiency guided data collection as an operational criterion, without implying comprehensive capture of the phenomenon. Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al. 2007).

Participants were selected through purposive sampling, prioritising diversity in years of experience, area of specialisation and geographical location, in order to capture a broad range of relevant perspectives. A total of 17 semi‐structured, in‐depth interviews were conducted, of which the first seven were analysed according to the criterion of thematic sufficiency (see Data S1) (Corbin and Strauss 2008; Saunders et al. 2018).

Inclusion criteria were: (1) healthcare or aviation professionals currently or previously working in HEMS in Spain; (2) a minimum of two years of HEMS experience; and (3) willingness to participate in an in‐depth interview. Although the study primarily focused on the experiences and perspectives of nursing professionals, other professional profiles involved in HEMS operations, including physicians and aviation personnel, were also included to provide complementary perspectives on the phenomenon under investigation. Their inclusion was intended to enrich the qualitative analysis by incorporating different professional viewpoints and operational experiences, thereby contributing to a more comprehensive understanding of the research topic. Exclusion criteria included professionals without direct HEMS experience or those unable to complete the interview.

The first seven interviews were analysed to assess thematic sufficiency, after which no new themes or conceptual dimensions emerged. Data collection nevertheless continued with ten additional interviews to examine the stability and diversity of the thematic framework across participants with different professional backgrounds, areas of expertise and levels of HEMS experience, while also exploring potentially divergent perspectives. These interviews did not generate new themes or conceptual dimensions but provided additional examples and greater depth within the existing framework. Thematic sufficiency was therefore used pragmatically to determine when the thematic framework was sufficiently stable to guide further data collection and analysis, rather than as evidence that the phenomenon had been exhaustively captured.

Thematic sufficiency was assessed through an iterative and concurrent process of data collection and analysis. Following each interview, transcripts were coded and compared with previously identified codes and themes using iterative comparison. Coding matrices were reviewed throughout the analytical process to assess whether the existing thematic framework remained adequate to account for the emerging data. Data collection continued beyond the point at which no new themes were identified in order to examine the stability of the thematic framework across participants with different professional backgrounds, areas of experience and levels of HEMS experience (Guest et al. 2006; Glaser and Strauss 1967).

The interviews were conducted either in secure professional settings or virtually, with an average duration of 45 to 60 min, and were recorded and transcribed verbatim to ensure data integrity.

The data were analysed using phenomenologically informed thematic analysis, aiming to identify and interpret the meanings participants attributed to their professional role, competencies and training experiences. A systematic coding process was undertaken using ATLAS.ti (v25.1), beginning with open coding to identify meaning units and followed by the organisation of codes into broader themes and subthemes. The analytical process comprised four stages: (1) identification of initial codes and candidate themes; (2) refinement and organisation of themes and subthemes; (3) exploration of relationships across themes; and (4) visual exploration of relationships among themes using semantic and functional networks (Friese 2012). Coding matrices developed in ATLAS.ti were reviewed after each interview to compare newly identified codes with the existing coding framework, allowing continuous assessment of thematic sufficiency.

Several strategies were used to enhance credibility and confirmability, including researcher triangulation, peer debriefing, peer review of codes and categories, and the use of verbatim quotations with interview numbers to ensure analytical traceability. The interviews were conducted by two nurse researchers (one man and one woman) with professional experience in HEMS and emergency care. Both held master's degrees and had academic experience in nursing and research, providing them with contextual knowledge of the clinical environment and the professional role of HEMS nurses. Before data collection, the researchers reflected on their professional experience, academic background and potential preconceptions regarding HEMS nursing competencies, training and professional role. This reflexive process continued throughout data collection and analysis to minimise the potential influence of the researchers' professional perspectives. No prior hierarchical or supervisory relationship existed between the interviewers and the participants. Reflexive discussions were held within the research team to examine emerging interpretations and challenge potential biases. Accordingly, the analytical procedures maintained a focus on participants' lived experiences and the meanings they attributed to their professional roles, while systematic coding and thematic development were used to enhance analytical rigour.

Participants provided informed consent, and the ethical principles of confidentiality and anonymity were upheld throughout the study. The study was approved by the Ethics Committee of the University of Valencia (Approval No. UV‐INV_ETICA‐4,222,615) and conducted in accordance with the principles of the Declaration of Helsinki. To enhance the credibility of the findings, researcher triangulation, peer debriefing and the use of verbatim quotations were employed. Member checking was not conducted, as the study prioritised these complementary strategies to support the consistency and transparency of the interpretation.

3. Results

A total of 17 professionals with experience in helicopter emergency medical services (HEMS) participated in the study (Table 1). Participants ranged in age from 34 to 52 years (mean age: 41.1 years), with 10 men and 7 women. The sample included 11 nurses, 5 physicians and 1 pilot. Among the nursing professionals, both pre‐Bologna University Diplomas in Nursing and Bachelor's Degrees in Nursing were represented, with additional postgraduate or doctoral qualifications. The physicians held Bachelor's Degrees in Medicine and postgraduate training in emergency medicine, while the pilot held a university bachelor's degree. Overall professional experience ranged from 8 to 25 years (mean: 17.7 years), whereas HEMS‐specific experience ranged from 4 to 20 years (mean: 10.9 years). Participants were based across 13 Spanish autonomous communities or territories, including Madrid, Catalonia, Ceuta, Castilla y León, Murcia, the Canary Islands, Aragon, Castilla‐La Mancha, Extremadura, the Balearic Islands, Andalusia, the Basque Country and Galicia. HEMS‐specific training also varied considerably and included HEMS university expert programmes, HEMS crew training, HEMS instructor qualifications, fixed‐wing air ambulance training, HEMS pilot training, flight dispatcher training and university qualification courses for healthcare professionals involved in HEMS missions. This diversity was retained to capture the range of professional profiles, experience levels, geographical settings and HEMS‐specific training represented within the Spanish aeromedical context.

TABLE 1.

Sociodemographic and professional characteristics of the participants (N = 17).

ID	Age	Sex	Region	Qualification and specialty	Years of experience	HEMS experience in years	HEMS specific training
1	46	Male	Madrid	University Diploma in Nursing (with Nursing Master)	21	6	HEMS University Expert
2	44	Men	Catalonia	University Diploma in Nursing (with Nursing Posgraduate)	22	16	HEMS Instructor – HEMS and Fixed Wing Air Ambulance Missions University Expert
3	35	Female	Ceuta	Bachelor's Degree in Medicine (with a Master in emergency medicine)	8	4	HEMS University Expert
4	43	Men	Catalonia	University Diploma in Nursing (PhD)	22	12	Flight Dispatcher
5	36	Women	Castilla‐and‐Leon	Bachelor's Degree in Nursing (with Nursing Master)	15	13	HEMS Crew Univeristy Expert
6	39	Men	Murcia	University Diploma in Nursing (with Nursing Master)	16	9	HEMS University Expert
7	44	Men	Canary Islands	University Diploma in Nursing (with Nursing Posgraduate)	24	18	HEMS and Fixed Wing Air Ambulance University Expert
8	39	Men	Aragon	Bachelor's Degree in Medicine (with a Master in emergency medicine)	18	12	HEMS and Fixed Wing Air Ambulance University Expert
9	52	Male	Castilla‐and‐La‐Mancha	University Diploma in Nursing (with Nursing Posgraduate)	25	20	University Qualification Course for health workers in HEMS missions; CRM training, and advanced health support.
10	37	Male	Extremadura	Pilot (with a University Bachelor's Degree)	15	12	HEMS Pilot
11	38	Female	Balearic Islands	University Diploma in Nursing (with Nursing Master)	15	9	HEMS University Expert
12	41	Male	Andalusia	University Diploma in Nursing (with Nursing Master)	18	10	HEMS University Expert
13	34	Female	Basque Country	Bachelor's Degree in Medicine (with a Master in emergency medicine)	9	5	HEMS University Expert
14	47	Male	Canary Islands	University Diploma in Nursing (PhD)	23	14	HEMS Instructor
15	40	Female	Balearic Islands	Bachelor's Degree in Nursing (with Nursing Posgraduate)	17	8	HEMS Crew Univeristy Expert
16	45	Male	Galicia	Bachelor's Degree in Medicine (with a Master in emergency medicine)	19	11	HEMS Crew Univeristy Expert
17	38	Female	Aragon	Bachelor's Degree in Medicine (with a Master in emergency medicine)	14	7	University Qualification Course for health workers in HEMS missions

For analytical purposes, prerequisites refer to requirements that participants considered necessary before entering HEMS practice (e.g., previous ICU experience); competencies refer to knowledge and skills developed for effective professional performance; and personal attributes refer to individual characteristics, such as emotional resilience and adaptability, that support safe practice within the HEMS environment.

Throughout the manuscript and figures, the terminology is used consistently: ‘prerequisites’ denotes requirements or prior preparation relevant to entry into HEMS practice; ‘professional competencies’ denotes knowledge and skills developed for effective professional performance; and ‘personal attributes’ denotes individual characteristics that support safe practice in the HEMS environment.

3.1. Key Emerging Concepts and Thematic Organisation of the HEMS Profile

The qualitative analysis identified a set of recurring concepts that characterised participants' descriptions of the HEMS nursing profile. These concepts encompassed specialised academic training, previous clinical experience, simulation‐based learning, technical and professional competencies, aerophysiology training, aviation safety and Crew Resource Management. Participants also referred to motivation, vocation, emotional adaptability and the need for preparation specifically oriented towards the operational demands of HEMS practice.

The emerging concepts were organised into four interconnected thematic areas: (1) access to the HEMS environment, including specialised academic preparation and previous clinical experience; (2) technical skills and competencies, including aerophysiology, advanced clinical procedures, aviation safety and Crew Resource Management (CRM); (3) professional perspective and role development, including motivation, vocation, emotional adaptability, autonomy and integration within the flight crew; and (4) structured professionalisation of the HEMS nursing profile, including the perceived need for specific training pathways and formal recognition of the role.

Across these areas, participants described the HEMS nursing profile as encompassing prerequisites, professional competencies and personal attributes. Previous clinical experience and specialised academic preparation were described in relation to access to HEMS practice, while simulation‐based learning and HEMS‐specific training were associated with the development of technical and operational competencies. Emotional adaptability, motivation and vocation were also identified in participants' accounts as relevant personal characteristics. These concepts provided the basis for the subsequent thematic analysis and the development of the four main categories presented below.

3.2. Thematic Analysis

The results of the qualitative analysis are presented in a structured format, organised around four main emerging categories. Each category is accompanied by its corresponding interpretation, supported by verbatim quotations that reflect the perceptions and meanings attributed by the participating professionals.

3.2.1. Basic Academic Training and Specific Training

Professional training in HEMS emerges as a central theme in the discourses analysed. It is not limited to obtaining formal qualifications, but rather entails a solid and specific foundation oriented towards the critical environment and aeromedical transport.

Most participants considered possession of a postgraduate degree (such as a Master's in Emergencies or a university expert qualification in medical transport) to be an important component of preparation for HEMS practice. This expectation is justified by the high technical and emotional complexity of the setting, as well as by the level of responsibility assumed by professionals in extreme situations.

Participants widely perceived fully online training as insufficient for developing the technical competencies required in HEMS practice and for preparing professionals to manage problems in real‐world scenarios. In contrast, practical training (particularly advanced clinical simulation) was positively valued and regarded as indispensable for bridging theoretical knowledge and operational practice.

Figure 1 illustrates the relationships between the subcategories identified within the category of basic academic training and specific training. Participants expressed these views as follows:

An online course does not teach you how to manage a critical patient in a helicopter (Interview 4).

There should be an official qualification, like in medicine: a master's degree or a specialisation (Interview 6).

Previous experience in critical care makes all the difference when you are up there on your own (Interview 7).

FIGURE 1.

Conceptual map of perceived relationships among HEMS competencies, experience and professional integration.

Participants described specialised training as comprising technical knowledge acquisition, formal education, clinical simulation and previous critical‐care experience. These elements were also associated in participants' accounts with perceived confidence, credibility and readiness for autonomous practice within the HEMS environment.

3.2.2. Work Experience and Prerequisites

Experience gained in intensive care units (ICUs), as well as in in‐hospital and out‐of‐hospital emergency departments, was described by participants as an important consideration for entry into the aeromedical field. Some participants proposed approximately five to eight years of clinical experience as a desirable level of professional maturity before entering HEMS practice. This proposed timeframe reflects participants' perceptions of professional maturity and should not be interpreted as an established minimum entry requirement for HEMS practice.

The relevance of supervised practical training as a transitional phase into the aeromedical environment was also highlighted. Although not all participants considered real‐flight experience to be essential, they placed significant value on simulated or supervised practice, which they perceived as useful for reducing uncertainty and supporting safe practice in the operational environment.

As illustrated in Figure 1, a clear distinction can be observed between the subcategories associated with the category of work experience and prerequisites. Participants expressed these ideas as follows:

No one should fly in HEMS without at least five years of ER or ICU experience. (Interview 5).

You really need around eight years of experience, at least four of them in the ER or ICU. (Interview 3).

Previous experience is what gives you the composure not to freeze in the middle of a flight. (Interview 8).

Simulated practices, even if they're not real flights, are essential and supervised practices too, they benefit both the patient and the professional. (Interview 1).

Participants reported that previous experience was relevant to their preparation for practice. They associated accumulated clinical experience with clinical judgement, emotional regulation and confidence when assuming responsibility in unpredictable situations. Participants also described previous experience as an important component of their professional development.

3.2.3. Specific Skills and Competencies

This category is closely linked to prior work experience, yet it places specific emphasis on the technical and operational competencies required for performance in HEMS. Training is not limited to theoretical knowledge; it encompasses skills that must be applied in adverse conditions, ranging from ultrasound‐guided vascular access to the use of advanced devices such as ECMO.

A key component of this skill set is understanding the pathophysiology of air transport, as factors such as hypoxia, vibration and pressure changes can alter both the patient's clinical presentation and the effectiveness of certain treatments and may even interfere with monitoring.

Participants perceived training in aviation safety and communication, particularly Crew Resource Management (CRM) and Helicopter Underwater Escape Training (HUET), as important potential components of HEMS preparation. These views reflect participants' perceptions and should not be interpreted as universally established or mandatory training requirements.

As illustrated in Figure 1, the relationships among the subcategories within the category of specific skills and competencies are shown. Some participants expressed these views as follows:

If you don't know how to manage a critical airway or perform ultrasound‐guided access, you can't fly with an unstable patient (Interview 2).

The pathophysiology of air transport should be part of the mandatory curriculum (Interview 9).

The helicopter environment has its own action protocols that must be known in advance (Interview 10).

CRM and HUET should not be optional. It's your life that's at stake if something goes wrong (Interview 5).

Participants described technical proficiency, aviation safety knowledge and communication skills as relevant competencies for nursing practice in the HEMS environment. They also described these competencies in relation to their integration into the operational context of aviation medicine and to the performance of nursing responsibilities within the flight crew.

3.2.4. Career Prospects and Development of the Specific Role

Beyond competencies and practical experience, participants emphasised the need for formal recognition of the HEMS role within the nursing profession, comparable to that granted to medical specialties. Participants described this demand as stemming from the multidimensional nature of the position, which requires clinical expertise, mastery of the operational environment and both physical and emotional adaptability. Far from being merely ‘flight technicians’, HEMS professionals must be fully integrated into the dynamics of the air crew and assume shared responsibility for critical decision‐making. Participants viewed emotional resilience as a fundamental attribute, given that professionals are frequently exposed to highly traumatic events, often in contexts characterised by substantial operational autonomy.

In this regard, the importance of adopting a comprehensive professional perspective is reinforced: the HEMS nurse is not confined to clinical duties but also assumes responsibilities inherent to the aeronautical setting. Participants described specialised training, technical competence, physical adaptability and emotional resilience as important elements for safe professional practice and effective performance in hostile, high‐pressure environments with limited access to external support.

As illustrated in Figure 1, the relationships among the subcategories within this category are presented below. Some participants expressed this as follows:

It should be recognised as a speciality, just as in medicine, and as those that already exist in nursing (Interview 5).

A HEMS nurse cannot be seen as a mere medical passenger; they are part of the crew (Interview 7).

You need to be in good physical condition; this kind of work is extremely demanding (Interview 6).

This work is highly demanding; you need strong emotional resilience to cope with it (Interview 4).

Participants described professional recognition in terms that extended beyond formal accreditation. They characterised the HEMS nursing role in relation to autonomy, shared responsibility and integration into the aviation environment. Participants also referred to technical expertise, emotional resilience and adaptation to operational constraints when describing their role and professional practice in HEMS.

3.3. Interpretative Conceptual Model of Perceived Relationships in the HEMS Nursing Professional Profile

Figure 2 presents an interpretative conceptual model, generated from participants' accounts, illustrating the perceived relationships among prior experience, specialised training, technical competence and professional integration in the development of the HEMS nursing role. The model represents the thematic relationships identified in the data rather than a validated or sequential developmental pathway. This model should therefore be understood as an interpretative representation of perceived relationships, not as a validated sequential pathway or a staged developmental trajectory.

FIGURE 2.

Conceptual map of perceived relationships among experience, training, competencies and professional integration in HEMS nursing. Colour key by category: BLUE: Basic and specialised academic training; GREEN: Work experience and prerequisites; YELLOW: Specific skills and competencies; RED: Career prospects and professional role development.

The colour‐coded structure facilitates the visual organisation of the concepts and their relationships. The blue group represents aspects related to basic and specialised training, including academic preparation, simulation‐based learning and participants' perceived limitations of fully online training. The green group includes requirements and previous experience, particularly accumulated clinical experience and emotional adaptability. The yellow group encompasses professional competencies and personal attributes, including technical and operational competencies, motivation, vocation and emotional adaptability. Finally, the red group represents advanced technical and operational training, including HEMS‐specific training, aerophysiology and Crew Resource Management (CRM).

The network illustrates the relationships identified across these dimensions. Specialised academic training and previous clinical experience are linked to access to HEMS practice, while simulation‐based learning, supervised practice and HEMS‐specific training are connected to the development of technical and operational competencies. Aviation safety, advanced technical skills, emotional adaptability, motivation and communication are also represented in relation to professional practice and integration within the flight crew. Overall, the map provides a visual synthesis of the thematic relationships identified in the interviews and complements the detailed analysis of the four main categories presented in the following sections.

3.4. Interrelations Across Emerging Categories

The analysis identified relationships among the four primary categories. Rather than functioning as isolated dimensions, these categories form a coherent framework that integrates prerequisites, training processes and professional performance within the HEMS environment. The most significant connections are described below, accompanied by representative quotations that illustrate each point:

3.4.1. Academic Training Versus Previous Professional Experience

Theoretical training is not considered sufficient unless it is supported by a solid foundation of clinical experience. Prior work in critical care units, such as ICUs or emergency departments, was perceived by participants as an important foundation for undertaking advanced HEMS‐specific training.

At a minimum, you need to have completed a university‐level HEMS expert qualification […] and have at least four years’ experience in ICU or emergency care. (Interview 1)

Theory collapses without experience. If you haven't lived the chaos of a real emergency, it's simply not enough. (Interview 2)

3.4.2. Practical Training and Simulation Versus Complex Technical Skills

The mastery of advanced competencies, such as mechanical ventilation, difficult airway management and ultrasound‐guided catheterisation requires repetitive, hands‐on practical training. Acquiring these skills solely through online instruction is considered insufficient

These techniques can only be developed through repetition […] if you don't do it, you won't know how to do it. (Interview 3)

Real practice can never be replaced by an online course. Your hands are trained, not read. (Interview 4)

3.4.3. Technical Skills Versus Expanded Professional Role

Participants associated the acquisition of technical skills not only with care‐related requirements but also with the development of a specialised and autonomous role integrated into the operational logic of the aeronautical environment.

HEMS nurses must be highly trained; they cannot improvise (Interview 5).

You cannot be a medical passenger; you are part of the crew (Interview 6).

3.4.4. Emotional and Physical Preparedness Versus Flight Conditions and Operational Stress

Participants described emotional resilience and physical fitness as personal attributes relevant to coping with work in hostile environments, under pressure and with limited external support.

Some interventions take place in remote areas that are difficult to access, so you need to be strong. (Interview 7)

You work in a small, noisy space with no external support. It's stressful and there's no monitoring. (Interview 8)

3.4.5. Aviation Safety and CRM Training Versus Professional Integration

Participants perceived aviation safety training, including CRM and HUET, as relevant to emergency preparedness and professional integration within the flight crew.

You cannot see yourself as a mere medical passenger […] you must be familiar with flight protocols. (Interview 9)

The difference between surviving or dying is having HUET training. (Interview 10)

4. Discussion

This study provides an in‐depth qualitative exploration of the perspectives of HEMS professionals regarding the role, competencies and professional development of nursing within aeromedical transport in Spain. Although nursing professionals constitute the primary focus of the study, the inclusion of other HEMS professionals, including physicians and aviation personnel, provides complementary perspectives that contribute to a broader and more comprehensive understanding of HEMS nursing practice.

The findings identified four interconnected thematic categories characterising the HEMS nursing profile: training, previous professional experience, technical and operational competencies and professional development. These findings highlight the importance of multidisciplinary perspectives in understanding the expansion of nursing scope of practice and the integration of advanced nursing roles within HEMS. Taken together, the findings may inform the future development of training programmes, accreditation strategies and professionalisation policies for HEMS nursing in Spain, while also contributing to the international discussion on nursing competencies within air medical transport services (Strony et al. 2022).

The first axis, linked to the expansion of advanced practice, highlights the technical and professional competencies required for HEMS nursing practice, which participants perceived as closely aligned with the specific demands of emergency care services and essential to sustaining professional performance in this environment. The involvement of nurses in advanced practice within emergency and intensive care settings has been shown to expand the nursing scope of practice, the second axis. In this regard, participants linked the acquisition of technical skills not only to care‐related requirements but also to the development of a specialised and autonomous role fully integrated into the operational logic of the aeronautical environment. The inclusion of nursing within HEMS teams has been associated with a range of reported benefits, including reduced hospital length of stay, shorter intervention times, lower mortality rates, improved patient satisfaction and more efficient use of healthcare resources (Trisyani et al. 2023). Given that the safety of passengers and crew on board HEMS aircraft is regarded by aviation professionals as a matter of paramount importance, crew training has increasingly incorporated advanced clinical simulation, both as a teaching method and as a strategy for acquiring theoretical knowledge and practical skills, enabling nurses to develop the clinical competencies and decision‐making abilities required to manage critical situations arising in daily practice (Triviño Ibarra and Mendoza Rodríguez 2024).

International comparison situates these findings within a broader disciplinary context. Although HEMS nursing has developed unevenly across countries, the competencies identified in this study align closely with those described in international aeromedical and critical‐care transport literature. The main divergence lies not in content but in the extent to which these competencies are formally defined, taught, assessed and recognised.

Recent qualitative studies from different aeromedical contexts further support the interpretation of HEMS competence as a multidimensional construct that extends beyond technical clinical skills. A study conducted in Taiwan identified challenges related to mission uncertainty, environmental hazards and cabin and equipment constraints, underscoring the need for situational simulation and expanded training to prepare nurses for the specific demands of air ambulance practice (Wang et al. 2024). Similarly, a study conducted in Indonesia identified several dimensions of aeromedical nursing practice, including prior evacuation experience, in‐flight challenges, essential knowledge and strategies for competency development and evaluation (Ambarwati et al. 2024). Together, these findings are consistent with the interpretation emerging from our data that HEMS competence involves the interaction of clinical expertise, aviation‐specific knowledge, environmental adaptation and structured preparation.

Evidence from Sweden further highlights the distinctive experiential dimension of aeromedical nursing. In a qualitative study of physicians and nurses involved in long‐distance transport of critically ill patients, participants described challenges associated with patient instability, high‐altitude conditions and confined, resource‐limited cabin environments, requiring substantial adaptation from standard hospital practice (Frost et al. 2019). These findings align with our participants' emphasis on clinical experience, autonomy, aviation safety and the ability to perform effectively under uncertainty and resource constraints. More recent research conducted in Brazil similarly identified healthcare, communication and management as interconnected nursing competencies in aeromedical transport, highlighting the need for continuing education to address existing knowledge and performance gaps (Borges et al. 2024). Taken together, these qualitative studies from diverse healthcare systems support the interpretation that HEMS nursing requires an integrated competency profile combining clinical, operational, communicative and adaptive capabilities.

In Japan, professional organisations and certification systems establish expectations for clinical competence, professional practice and transport‐nursing preparation, spanning advanced clinical knowledge, critical‐care experience, leadership, decision‐making and familiarity with the aircraft environment (Omori et al. 2025). These domains mirror our findings, particularly the emphasis on advanced clinical skills, aviation safety, crew resource management (CRM) and prior experience in emergency and critical care.

Notably, participants did not regard HEMS competence as an extension of conventional emergency nursing, but as a distinct professional profile integrating clinical expertise with operational and aeromedical competence.

Previous clinical experience emerged as a further point of convergence. Participants linked professional maturity to prior intensive care and emergency experience and described five to eight years of clinical experience as a plausible benchmark for developing the maturity they associated with HEMS practice. Some participants perceived substantial prior clinical experience, particularly in critical care and emergency settings, as important preparation for HEMS practice. Several participants proposed approximately five to eight years of clinical experience; however, this should be understood as a participant‐derived perception rather than an empirically established minimum entry requirement for HEMS nursing practice. International models similarly emphasise substantial critical‐care experience before aeromedical responsibilities are assumed (Omori et al. 2025), while Australian evidence highlights the relevance of prior clinical experience, autonomy and adaptability to resource‐limited settings (Martin and Kumar 2020). Such experience should therefore be understood not as a fixed administrative entry criterion, but as a component of competency development.

The United Kingdom illustrates an alternative pathway, in which professional development draws on broader national nursing, emergency and critical‐care frameworks rather than a HEMS‐specific structure (Wit et al. 2023), a model of potential relevance to Spain, where a future framework could align with existing advanced‐practice standards while incorporating additional aeromedical requirements. New Zealand offers an even closer parallel, having explicitly conceptualised flight nursing as a specialised practice area encompassing critical‐care experience, advanced clinical skills, flight physiology, aviation safety, survival training, crisis management and psychological fitness (Le Roux et al. 2025; Will 2025), domains that correspond closely to our four thematic areas: prerequisites, professional competencies, personal attributes and professionalisation.

Simulation‐based education represents a further area of convergence. Participants valued practical, high‐fidelity training over purely online instruction for technical competencies, consistent with international programmes combining simulation, CRM and structured debriefing across helicopter and ambulance‐jet crews (Nabecker et al. 2021). Because critical HEMS procedures are often infrequent, on‐the‐job exposure alone may be insufficient to sustain competence, as shown in a German HEMS system supporting dedicated interdisciplinary simulation (Mockler et al. 2023); however, no study or law guarantees a minimal response time (Burillo‐Putze et al. 2001). Japanese developments similarly combine e‐learning with simulation to standardise training and assess technical competencies and personal attributes (Omori et al. 2025), suggesting that simulation may be an important component of HEMS preparation.

CRM is a team‐development strategy that promotes effective management of human factors and the development of non‐technical skills that complement clinical competencies. Previous evidence has examined the relationship between CRM training and clinical simulation (Casal Angulo et al. 2020). Simulation may provide a useful educational approach for assessing team performance and supporting professional practice through structured scenarios and feedback (Strony et al. 2022; Gaba 2004). However, the present qualitative study did not assess whether simulation directly improves patient safety or clinical outcomes. CRM proved particularly salient: participants considered it, alongside aviation safety training, essential, echoing international programmes that integrate communication, leadership and human‐factors training with technical procedures (Nabecker et al. 2021). The findings suggest that CRM may be understood as a broader operational competency involving shared situational awareness and coordinated decision‐making within the flight crew, rather than as a discrete communication course.

These parallels suggest that the domains identified in Spain are not idiosyncratic but reflect competency areas recurring across aeromedical systems internationally, particularly regarding critical‐care experience, clinical skills, aviation safety, CRM and simulation. The contribution of this study therefore lies not in redefining HEMS competence, but in showing how these domains are perceived and prioritised within the Spanish context, where the principal divergence concerns institutional formalisation rather than substantive content: Spanish HEMS nursing appears highly specialised in practice yet insufficiently structured at the system level. This gap, rather than an absence of recognised competence, may inform the development of a future Spanish competency framework addressing entry requirements, clinical and aeromedical skills, CRM, simulation and mechanisms for continuing assessment, using international models as benchmarks rather than direct templates.

Importantly, recommendations concerning prior clinical experience, postgraduate preparation, simulation, online education, CRM, HUET and formal accreditation represent participants' perceptions and proposed implications arising from the qualitative data. They should not be interpreted as established minimum requirements or validated standards. Further empirical research and, where appropriate, consensus‐based processes are required before such elements can be incorporated into formal educational, competency, or accreditation frameworks.

4.1. Implications for Nursing Practice

The findings have several implications for HEMS nursing practice, education, leadership, competency development and professional preparation. For HEMS nurses, the participants' accounts highlight the importance of integrating advanced clinical knowledge with aeromedical and operational competencies, including awareness of the specific environmental conditions of flight, aviation safety, communication and Crew Resource Management. These findings may support nurses and HEMS services in identifying areas for continuing professional development and in considering how clinical and operational competencies can be maintained in practice.

For nurse educators, the findings suggest that HEMS preparation may benefit from educational approaches that combine theoretical learning with supervised practice and simulation‐based activities. Participants particularly valued practical and simulation‐based preparation for developing confidence in managing complex clinical and operational situations. These findings may inform the design of future educational programmes, although the present study does not establish the effectiveness of any particular educational modality or demonstrate that simulation produces improved patient outcomes.

For nursing leadership, the findings may support consideration of clearer professional development pathways for nurses working in HEMS. Leadership teams may consider how induction, supervision, continuing education, competency assessment and opportunities for professional development can be structured within local HEMS services. The findings also highlight participants' perceptions of the importance of integrating nurses as active members of the multidisciplinary flight crew, with shared responsibility for communication, coordination and decision‐making.

Regarding competency development, the findings support a multidimensional view of HEMS nursing competence encompassing clinical and technical skills, aeromedical knowledge, operational and communication competencies and personal attributes relevant to working in demanding environments. Importantly, these domains emerged from participants' perceptions and should not be interpreted as a validated competency framework. Further research is needed to determine which competencies should be formally defined, how they should be assessed, and whether specific educational or assessment strategies are associated with improved professional performance or patient outcomes.

Finally, with regard to professional preparation, participants described previous critical‐care and emergency‐care experience, specialised education, supervised practice and simulation as relevant components of preparation for HEMS practice. The proposed five to eight years of prior clinical experience should be understood specifically as a participant‐derived perception rather than an empirically established minimum entry requirement. Similarly, participants' views regarding postgraduate education, CRM, HUET and other forms of specialised preparation should be regarded as proposed educational or professional considerations requiring further evaluation. Collectively, these findings may contribute to future discussions concerning the development of structured HEMS nursing education and competency pathways in Spain, while further empirical and consensus‐based work is needed before formal requirements or accreditation standards are established.

4.2. Limitations

The present study is subject to several limitations inherent to qualitative designs. Firstly, the limited sample size and the purposive selection of participants, while allowing for an in‐depth exploration of experiences and perceptions, restrict the generalisability of the findings to all HEMS nursing professionals in Spain or other international contexts.

Secondly, data collection through in‐depth interviews may be affected by self‐reporting biases, such as social desirability or memory‐related distortions. This could influence the accuracy of the perceptions expressed.

Moreover, despite the implementation of rigorous qualitative procedures, including researcher triangulation, peer review of codes and thematic sufficiency, the interpretation of the data remains influenced by the research team's analytical perspective, which may introduce a degree of interpretative influence inherent in the qualitative analytical process. The relationships described in this study are interpretative and perception‐based; they do not establish causal effects of training, simulation, or aviation‐safety education on clinical outcomes.

Finally, although the study did not focus exclusively on HEMS nurses, nursing professionals constituted the majority of the sample (11 of 17 participants), while other professional groups were represented by smaller numbers (five physicians and one pilot). The perspectives of these other HEMS professional groups were therefore included, but the relatively small number of participants, particularly aviation personnel, limits the extent to which their perspectives can be explored in depth. This imbalance in professional representation may have influenced the breadth of the findings regarding the broader multidisciplinary and operational dynamics of the aeromedical environment. Future research should include larger and more balanced samples across professional groups to further explore these perspectives and complement the present findings.

Despite these limitations, an important strength of this study lies in its ability to provide an in‐depth understanding of the professional profile of HEMS nurses from the perspective of experienced practitioners. Rather than representing isolated competency domains, the findings illustrate how participants perceived previous critical‐care experience, specialised education, competency development and operational integration as interconnected dimensions of HEMS professional practice. This interpretative perspective extends beyond a description of competencies by highlighting the social and professional processes through which expertise is recognised and enacted.

Finally, member checking was not conducted, which may have limited the opportunity for participants to review or clarify the researchers' interpretations. Credibility was nevertheless supported through researcher triangulation, peer debriefing, reflexive discussions, analytical traceability through the use of verbatim quotations with interview numbers and systematic coding procedures.

5. Conclusion

This study provides a qualitative characterisation of the HEMS nursing profile in Spain, highlighting competency domains that participants considered important for practice, including advanced clinical competencies, previous experience in critical‐care environments and specific technical and operational skills. Participants also emphasised the relevance of specialised academic training, accumulated experience in ICUs and emergency departments and practical preparation through clinical simulation and supervised practice. Fully online training was generally perceived as insufficient for developing the competencies required in HEMS practice, whereas simulation and CRM were valued as components of technical and non‐technical training.

Furthermore, participants noted the importance of formal recognition of the HEMS nursing role, particularly in relation to professional autonomy and shared responsibility during transport. Emotional resilience and physical adaptability were identified as relevant personal attributes, alongside integration within the air crew as an aspect of professional practice.

Overall, the findings indicate that participants perceived a structured training pathway integrating hands‐on practice, simulation‐based training and psychological and physical preparation as potentially relevant to HEMS nursing development. These findings may inform future discussions on standardised training programmes, professional accreditation and policy development for HEMS nursing in Spain; however, such elements should not be interpreted as established requirements or standards on the basis of the present qualitative study. Further research and professional consensus are needed before formal training or accreditation requirements are established.

Author Contributions

Alejandro Artero‐García: conceptualization, data curation, methodology, software, investigation, validation, formal analysis, project administration, supervision, resources, writing – review and editing, visualisation, writing – original draft. Luciano Rodríguez‐Díaz: conceptualization, data curation, investigation, writing – original draft, writing – review and editing, visualisation, validation, methodology, software, formal analysis, project administration, supervision, resources. Carmen Casal‐Angulo: investigation, writing – original draft, methodology, validation, visualisation, writing – review and editing, data curation, resources, formal analysis. Regina Allande‐Cussó: investigation, writing – original draft, writing – review and editing, visualisation, methodology, formal analysis, data curation, resources. Javier Fagundo‐Rivera: investigation, writing – original draft, methodology, validation, visualisation, writing – review and editing, formal analysis, data curation, resources. Juan Gómez‐Salgado: investigation, writing – original draft, methodology, validation, visualisation, writing – review and editing, formal analysis, resources, data curation.

Funding

The authors have nothing to report.

Ethics Statement

Participants provided informed consent, and the ethical principles of confidentiality and anonymity were upheld throughout the study. The study was approved by the Ethics Committee of the University of Valencia (Approval No. UV‐INV_ETICA‐4,222,615) and conducted in accordance with the principles of the Declaration of Helsinki. To enhance the credibility of the findings, researcher triangulation, peer debriefing and the use of verbatim quotations were employed. Member checking was not conducted, as the study prioritised these complementary strategies to support the consistency and transparency of the interpretation.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Summary of Data Extracted from Interviews Not Analysed.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.