Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

65

The impact of ASEAN economic community

on healthcare service as expected by directors
of hospitals and directors of nursing, and their
intention to formulate strategic planning for
preparation toward the ASEAN economic
community
Nongnut Boonyoung*, Sasitorn Phumdoung**

Abstract

Purpose: ASEAN economy community (AEC) has been widely recognized
as beginning a big change to AEAN member countries in all aspects including the
healthcare system. Potential changes to healthcare system from the AEC were one
area of concern by involved stakeholders, especially administrators in hospitals
who have paid attention to further preparation. This descriptive study aimed to 1)
explore the expectation of the impact of AEC on healthcare service, and 2) examine
the intention to formulate strategic planning for preparation toward the AEC of
directors of hospitals (DH) and directors of nursing (DN).

Methods: The sample was 85 DHs and 85 DNs from medical universities
and tertiary and general public hospitals across Thailand. The sample was
purposively selected from medical universities and tertiary hospitals, but that from
general hospitals was recruited by simple random sampling. The instrument was
developed by the researchers and comprised three parts: 1) a demographic form,
2) a self-administered questionnaire regarding the intention to formulate strategic
planning for preparation toward the AEC, and 3) a self-administered questionnaire
regarding the expectation of the impact of AEC toward healthcare service.

Results: Both directors of hospital and directors of nursing expected that
there were positive impact of AEC on health care services. The number of items
of the expectation toward the positive impacts are more than those of negative
impacts of the AEC on healthcare services in the near future. In addition, the
directors of hospital were less likely to have intention to formulate the strategic
planning as compare to that of directors of nursing.

Conclusion: The preliminary results revealed likelihood of positive impacts
more than negative impacts. Both hospital directors and director of nursing had
intention for developing the strategic plan for better preparation for the AEC
Keywords: impact; ASEAN Economic Community; intention; strategic
formulation; preparation
* Associate Professor, Department of Nursing Education and Nursing Service, Faculty of Nursing,
Prince of Songkla University, Thailand.
** Associate Professor, Department of Obstetric Gynecology and Midwifery, Faculty of Nursing,
Prince of Songkla University, Thailand.

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Introduction

ASEAN Economy Community (AEC) has been widely recognized as
a big change to AEC member countries in all aspects including the healthcare
system. Potential changes to healthcare system from the AEC were one area of
concerns for stakeholders, especially administrators in hospitals who should
pay attention for further preparation. The administrators can foresee the trend
of potential changes as well as the magnitude of changes in order to formulate
the strategic plan to provide effective management and lead the hospitals to
achieve their vision. It has been accepted that the better management for the
change from the well-developed strategic plan that guide the direction1, the
smarter approaches to provide healthcare services for all groups of clients both
Thai people and clients from other AEC member countries.
Purposes

The purposes of this study were to explore the impact of AEC on healthcare
service as expected by directors of hospitals and by directors of nursing in
secondary and tertiary hospitals under Ministry of Public Health and in tertiary
hospitals for medical schools across nation and to examine the intention to
formulate strategic planning for preparation toward the AEC of directors of
hospitals and of director of nursing in secondary and tertiary hospitals under
Ministry of Public Health and in tertiary hospital for medical schools across
the nation
Methods

Design

This study was a descriptive research. The population was directors of
hospital (DHs) and directors of nursing (DNs) working in 38 hospitals for medical
schools across Thailand and 67 secondary hospitals. The total population was
105 DHs and 105 DNs.

Sample

The sample comprised two groups. The sample in group I were 85 DHs
from 38 DHs who has at least one year experience as DH from 38 tertiary hospitals.
They were recruited by purposive sampling; and 47 DHs from secondary hospitals
from 67 secondary hospitals were selected by random sampling technique. The
sample in group II were 85 DNs from 38 tertiary hospitals who has at least one year
experience as DN, recruiting by purposive sampling; and 47 DHs from secondary
hospitals were selected by simple random sampling.

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Instrument

The instrument consisted of three parts. Part I was a demographic data with
yes-no questions and fill-in the blank, part II was a 60-item questionnaire related
to the the impact of AEC (EI-AEC) on healthcare service as expected by directors
of hospitals and by directors of nursing which was developed by researchers based
on Westley and Mintzbergs visionary leadership and strategy management2 (1989).
The expectation to the impact identified as positive impact (score=2) and negative
impact (score=1) and no impact (score=0). The high score refers to high impact of
each item. Part III was a 58-item-questionnaire regarding the intention to formulate
strategic planning (IFSP) for preparation toward the AEC of directors of hospitals
and of directors of nursing, which was developed by the researchers based on
Anspaugh, Dignan, & Anspaughs theory of reasoned action3 (2000). The part
III scale was a Likert scale with score ranging from 1-5; 1 refers to the lowest
intention to formulate the strategic plan, and score 5 refers to the highest intention
to formulate the strategic plan. The instrument part II and part III were tested
for content validity by three experts and revealed a value of CVI = .81 and .81
respectively, and test the reliability with a group of 24 administrators yielding values
of Cronbachs alpha coefficient as 0.86 and 0.92 respectively. The interpretation of
the instrument part III was as follow: 1.00-2.33 means the DHs/DNs had intention
to formulate the strategic plan at a low level, 2.34-3.67 means the DHs/DNs had
intention to formulate the strategic plan at a moderate level, 3.68-5.00 means the
DHs/DNs had intention to formulate the strategic plan at a high level. The questionnaires were sent directly to the DHs and DNs with a written consent form as well as
a returned-envelope to the principle investigator. Data were collected three months
from January-March 2013.

Data analysis

The demographic data were analyzed using frequency, percentage, mean
and standard deviation; Part II: The EI-AEC was analyzed by percentage, and Part
III: the IFSP was analyzed by mean and standard deviation. The rate of returned
questionnaires from directors of hospitals was 67 from 85 which was 78.82%, and
that from directors of nursing was 81 from 85 which was 95.29 %
Results

The sample in a group of directors of hospital (DHs) mostly were male
(91.8%), half of them had work experience as DH for 1-5 years (50.9%), most
of the sample attended the AEC conference within past two years (70.5%) and
attended twice in average (M= 1.92, SD =2.76), almost 30% of sample were from
central Thailand (29.5%), almost all of sample reported that their hospitals had
clients from other countries during the past two years (98.4%). Almost 60%
of sample reported that in the next three years AEC had little impact for their

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management (59.0%) and very few (3.3%) perceived high impact and nearly
half of sample perceived that AEC would impact their service (45.9%), one-third
perceived that AEC had an impact on their hospitals budget (34.5%) and reported
the unexpected impact on the budget (32.7%). More than half of the sample had the
strategy plan ready for the AEC (63.9%), Most of them reported that the policy of
the Ministry of Public Health most influenced the adjustment of hospital strategy
(75.4%)

The sample in a group of director of nursing (DNs) mostly were female
(96.3%), half of them had work-experience as DNs for 1-5 years (77.8%), most of
sample attended the AEC conference in the past two years (82.7%) and attended
twice in average (M= 2.12, SD =1.62), approximately one-third of sample were
from central Thailand (34.6%), almost all of sample reported that their hospital had
clients from other countries during the past two years (96.3%). Approximately half
of the sample reported that in the next three years AEC had little impact on their
management (51.9%), and very few perceived high impact (2.5%), one-third of
sample perceived that AEC would impact their service (37.0%), 42.0% perceived
that AEC had an impact on their hospital budget, whereas, nearly half of them
reported unexpected impact on the budget (45.7%). Most sample had the strategy
plan ready for the AEC (71.5%), and reported that the policy of the Ministry of
Public Health most influenced the adjustment of hospital strategy (65.4%).
Table 1
Frequency and percentage of DHs and DNs in expectation toward impact of AEC
on process of medical treatment

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From Table 1, most sample in the group of DHs expected the positive impact
of AEC on process of medical treatment in these following items: surveillance/
health protection (85.2%), communication (77.0%), using other languages (77.0%),
manage patient information system, modify the hospital main system, and modify
medical charge (75.4%) respectively. However, more than half of the sample
perceived no impact on emergency preparation (55.7%), the speed of healthcare
service (52.4%), and using technology (50.9) respectively. Most sample in the
group of DNs expected the positive impact of AEC on these following items
including surveillance/health protection (96.3%), manage patient information
system (96.3%), using other languages (93.8%), communication (91.4%), modify
the hospital main system (84.0%), infection control (81.5%), develop continuity of
care (79.0%), and modify medical charge (77.8%).
Table 2
Frequency and percentage of DHs and DNs in expectation toward impact of AEC
on characteristics of the services

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From Table 2, most sample in the group of DHs expected the positive
impact of AEC on characteristics of the services in these following items: provide
IT service for client (85.2%), work load from the service and support staff for
multicultural care (80.3%). In addition, more than half of them perceived that no
any impact from the AEC (54.1%). Most sample in the group of DNs expected the
positive impact of AEC on these following top-five items: support staff for multicultural care (97.5%), provide IT service for client (96.3%), work load from service
(91.4%),care for high-risk foreigner clients (91.4%), and public relation with client
from other country (90.1%). Half of both groups: DHs (54.1%) and DNs (49.4%)
reported no expectation of the impact on care provision for Thai people.
Table 3
Frequency and percentage of DHs and DNs in expectation toward impact of AEC
on product of health care services

From Table 3, most sample in the group of DHs expected the positive impact of AEC on product of healthcare service in number of international clients
(82.0%), more than half of them expected that AEC brought new project related
to healthcare service (65.5%), perception of hospital image (55.7%), performance
and budget (57.4%), staff attrition (54.1%) whereas, they expected no impact on
level of quality of care (61.3%). For the group of DNs, they expected the positive
impact of the AEC on the top-three following items including international clients
(91.4%), new project related to healthcare service (77.8%), and budgeting (70.4%),
whereas, one-third of them perceived no impact on level of quality of care (34.5%).

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Table 4
Number and percent of DHs and DNs by the expectation toward impact of AEC on
organizational management

From Table 4, sample in the group of DHs expected the positive impact of
AEC on the organizational management. The top-three items were: training head
of unit about law in healthcare system for AEC (80.3%), working climate for AEC
(73.8%), and develop organizational competency (72.1%) respectively, whereas,
some DHs (14.8%) expected negative impact on maintaining talent staff. Most of
those in the group of DNs expected training for head of unit about law in healthcare
system for AEC (91.1%), working climate for AEC (85.2%), and set the expert
area (81.5%), and modify leading process (81.5%). In addition, nearly half of
both group: DHs (47.5%) and DNs (45.7%) expected no impact of AEC on renew
organizational structure.

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Table 5
Frequency and percentage of DHs and DNs in expectation toward impact of AEC
on marketing

From Table 5, sample in the group of DHs expected the positive impact of
AEC on marketing. The top-items were: expand new groups of clients (75.4%),
offer new package for care (68.9%), and strengthen network (67.2%). For the
group of DNs, the top-three items were: expand new groups of clients (85.2%),
support for service (80.4%) and listen to reflection from client (84.0%), and offer
new package for care (80.2%). In addition, approximately 40% of both group:
DHs (42.6%) and DNs (40.7%) expected no impact of AEC on competition among
hospitals.
Table 6
Mean, standard deviation, and level of intention to formulate strategic planning for
the AEC among DHs and DNs

From Table 6, the overall mean score of intention to formulate strategic
planning for AEC as perceived by the group of DHs (M=3.61, SD=.67) was at
a moderate level. When considering key steps of strategic planning, mean score
of each step including goal setting (M=3.57, SD=.66), environmental analysis
(M=3.61, SD=.69), and formulation of strategy (M=3.65, SD=.74) was at a moderate
level. For the group of DNs, the overall mean score of intention to formulate strategic
planning for AEC (M=3.86, SD=.53) was at a high level. The mean score of each
step regarding the intention to formulate strategic planning for AEC including
goal setting (M=3.97, SD=.63), environmental analysis (M=3.85, SD=.54), and

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formulation of strategy (M=3.97, SD=.62) was at a high level. In addition, the DNs
overall mean score of intention and the mean scores of environmental analysis
and formulation of strategy were statistically significant higher than those of DHs
at .05 (p<.05).
Discussion

Most directors of hospital (85.2%) and directors of nursing (96.3%) expected
the surveillance/health protection as the positive impact of the AEC on the process
of medical treatment (Table 1) as the surveillance/health protection is the proactive
role of knowledgeable healthcare personnel4 that reflects a high standard of care
and a value of protection and prevention is higher than cure. In addition, currently
Thailand health care system has welcomed international clients as reported by
almost of the DHs (98.4%) and DNs (96.3%), therefore, the DHs and DNs envision
the value of healthcare personnels ability to assess and monitor for any warning
sign of some potential health problems which leading to the high quality and
cost-effective healthcare provision5, whereas the hospitals were able to maintain
their speed and convenience of their service as reported by more than half of the
DHs (52.4%) and almost half of the DNs (44.5%) perceived no impact of AEC.

Most DHs (85.2%) and DNs (96.3%) expected positive impact on the
characteristics of the service including providing IT service for clients (Table 2).
This is because at present, the modern technology related to health care system
such as computer-based information, medical equipment, and other communication
technologies were attractive for clients and healthcare personnel to communicate
each other for better understanding about the plan of care6. Also, from the
perspective of administrators, the ability to collect and analyze data through available
technology will decrease the paper work. The IT service is the useful tool for the
administrators as well as for clinicians that can be planned in advance for different
groups of clients especially for Thai people and for international clients. At the
meantime, the current study showed that most DHs (82.4%) and DNs (91.4%)
expected that there was an increasing numbers of international clients (Table 3) who
would utilize Thailand healthcare service and speak different languages as members of AEC countries such as English, Chinese, and Myanmar. Therefore, providing IT service for clients was the high volume of positive impact to further prepare
for the AEC. In addition, both two-third of the DHs (61.3%) and one-third of the
DNs (34.5%) perceived that the AEC could cause no impact on quality of care.
But, majority of DHs (80.3%) and DNs (91.1%) who attended the AEC conference
expected a great need for training of heads of units on law in healthcare system
when AEC has been fully developed (Table 4) as because most international clients
who will be a new challenging group of clients, as expected by most DHs (75.4%)
and DNs (85.2%) (Table 5), are concerned about human rights to receive an
appropriate treatment7 that suitable with their set of belief and values as well as a
right to reasonably pay for the healthcare cost.

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The overall mean score of intention to formulate strategic planning for AEC
as perceived by the group of DHs (M=3.61, SD=.67) was at a moderate level (Table
6) which can be explained that some DHs would like to keep the services in the
same manner even though the AEC is occurring in the next two years as because
most DHs work in public hospitals, they have to wait and listen to the policy of
Ministry of Public Health as it is the most influencing factor for the adjustment of
hospital strategy (75.4%). At the mean time, the current services are well delivered
to the clients and well-organized as more than half of the DHs perceived no impact
on these following items: emergency response (55.7%), care provision for Thai
people (54.1%), the level of quality of care (61.3%). In addition, one-third of the
DHs were from central Thailand (29.5%), whereas most DHs were from different
regions in Thailand. The hospitals located in central Thailand may have higher
chance of having the international clients than other parts of the country. The DHs
in the central part of Thailand might need to develop or modify their strategic plan
to well-prepare for the possible coming of foreigner clients, but the rest of DHs still
use their previous strategic plan to serve their people. So, the DHs expressed their
intention to formulate the strategic plan at a moderate level.

For the DNs, the overall mean score of intention to formulate strategic
planning for AEC (M= 3.86, SD = .53) was at a high level which can be explained
that the DNs were mainly responsible for leading and managing nursing practices
of nurses who must provide direct and suitable care for all clients both from
Thailand and other countries. Also, the nature of the nursing profession is to interact
with the clients based on the patient-care centered approach. Therefore, the nurses
have to use the strategy to meet the clients need, especially in the near future the
potential international clients are more likely to increase, there is a great need for
nurse administrators to develop or modify their strategy for handling the appropriate
care among the multicultural clients8. In addition, most DNs worked in public
hospitals under the Ministry of Public Health, a service-based oriented hospital
with unlimited in number of admission, therefore there is a great push for
formulating the strategic planning to better enhance the effectiveness of administration
and management which lead the DNs to express their intention at the high level
which is greater than that of the DHs. But for goal setting, both the DHs and DNs
who are the executives of the hospitals and the nursing departments generally set
the ultimate common goal similarly, that is providing care for the clients with high
standard.
Conclusion

Both directors of hospital and directors of nursing expected that there
were positive impact of AEC on health care services. The number of items of the
expectation toward the positive impacts are more than those of negative impacts
of the AEC on healthcare services in the near future. In addition, the directors of
hospital were less likely to have intention to formulate the strategic planning as
compare to that of directors of nursing.

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Suggestion for Future Research:

1) To develop the guideline for enhancing healthcare personnel for better
adaptability to upcoming AEC.

2) To explore factors contributing to the speed and convenience of
healthcare services.

3) To study the relationship between the intention for formulation the
strategic planning and the outcomes of the achievement of the key performance
indicators regarding the changes from the AEC.
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