Future Directions for Community Nursing in Thailand: A Competency-Based Model for Subdistrict Health Promoting Hospitals Following Decentralization; A Mixed-Methods Study

Abstract

Introduction: The decentralization of Subdistrict Health Promoting Hospitals (SHPHs) to Provincial Administrative Organizations (PAOs) in Thailand represents a significant structural reform with direct implications for nurses working in primary healthcare settings. This study aimed to develop a competency model for nurses employed in SHPHs under PAO jurisdiction, ensuring alignment with decentralization policies and local health system needs. Methods: A mixed-methods design was used in 2 phases. Phase 1 employed qualitative methods to explore current nursing roles through in-depth interviews and thematic analysis. Phase 2 involved developing the competency model using quantitative data and the Delphi technique with expert consensus. Results: Findings from phase one indicated that nurses continue to play a vital role in community-based health promotion and care for vulnerable populations. Following decentralization, nurses have adapted to new responsibilities involving local workforce coordination, budgeting, and health information systems, necessitating expanded competencies. The competency model delineates stratified expectations by facility size: small SHPHs require generalist proficiency for autonomous service delivery; medium SHPHs necessitate specialized and collaborative competencies for programmatic functions; and large SHPHs demand advanced skills in systems management, strategic planning, and specialized care to align with institutional complexity. Conclusion: Although nurses’ core responsibilities in primary care remain central, decentralization has introduced new demands requiring advanced clinical, technological, data management, and interprofessional collaboration competencies. These expanded roles have strengthened nurses’ contributions to local health governance under the PAO system.