急診護理師位處醫療體系第一線，除臨床照護工作外，亦承擔健康政策執行與制度落實之重要角色。然而，急診場域長期面臨急診壅塞、病患滯留、護理人力不足及病情高度不確定等挑戰，使第一線人員經常必須在有限時間與資源條件下進行判斷與決策。在此情境下，裁量權不僅是臨床工作的實務需求，更是健康政策得以落實的重要機制。相較於社會福利、教育或警政等領域，國內關於醫療場域基層官僚裁量行為之研究仍相對有限，尤其缺乏對急診護理師政策執行經驗之深入探討。 本研究以Lipsky （1980）基層官僚理論為主要分析架構，並結合Zacka（2017）有關技術裁量、規範裁量與道德能動性之觀點，探討急診護理師於健康政策執行過程中的裁量實踐。研究採質性研究方法，以桃園市某公立醫療院所急診部門為研究場域，透過深度訪談、現場觀察及文件分析蒐集資料，進行主題分析。 研究結果顯示，急診護理師之裁量並非制度偏離或個人任意決定，而是在高度不確定與資源受限情境下所形成之常態性實務運作模式。受訪者普遍指出，面對病情快速變化與急迫處置需求時，護理師往往需依據專業知識、臨床經驗及現場資訊進行判斷，透過病情評估、檢傷分級、優先排序及資源調配等方式回應病人需求。與此同時，護理師亦須在病人安全、照護品質、制度規範及資源限制之間持續進行權衡與取捨。研究亦發現，健康政策於急診現場並非被動執行，而是在第一線工作者持續詮釋、調整與實踐的過程中逐步形成具體樣貌。 理論上，本研究驗證基層官僚理論於急診醫療場域之解釋力，進一步指出急診護理師之裁量不僅涉及專業技術判斷，更包含價值選擇與倫理考量。研究結果顯示，健康政策之執行係透過第一線工作者之專業實踐被具體化與在地化。實務上，未來制度設計宜由單純強調控制與監督，轉向建構支持性裁量環境，透過明確授權、法制保障、組織支持及合理人力配置，讓第一線人員於兼顧病人安全與制度要求下發揮專業判斷，以提升政策執行效能及醫療體系韌性。;Emergency Department (ED) nurses serve on the front line of the healthcare system， playing a crucial role not only in providing clinical care but also in implementing health policies and organizational regulations. However， emergency care settings are consistently confronted with chronic challenges， including ED overcrowding， patient boarding， nursing workforce shortages， and high levels of clinical uncertainty. Under these circumstances， frontline healthcare professionals are frequently required to make judgments and decisions within severely compressed timeframes and under significant resource constraints. In this context， discretion is not merely a practical necessity in clinical practice but also a critical mechanism through which health policies are translated into practice. Compared with research in the fields of social welfare， education， and policing， studies examining discretionary behavior among street-level bureaucrats in healthcare settings remain relatively limited in Taiwan， particularly with respect to emergency department nurses′ experiences in health policy implementation. This study adopts Lipsky′s (1980) Street-Level Bureaucracy Theory as its primary analytical framework and draws on Zacka′s (2017) conceptualization of technical discretion， normative discretion， and moral agency to examine how emergency department nurses exercise discretion in implementing health policies. A qualitative research design was employed， with the emergency department of a public medical institution in Taoyuan City serving as the research site. Data were collected through in-depth interviews， field observations， and document analysis， and subsequently analyzed using thematic analysis. This study adopts Lipsky′s (1980) Street-Level Bureaucracy Theory as its primary analytical framework and draws on Zacka′s (2017) conceptualization of technical discretion， normative discretion， and moral agency to examine how emergency department nurses exercise discretion in implementing health policies. A qualitative research design was employed， with the emergency department of a public medical institution in Taoyuan City serving as the research site. Data were collected through in-depth interviews， field observations， and document analysis， and subsequently analyzed using thematic analysis. From a theoretical perspective， this study confirms the applicability of Street-Level Bureaucracy Theory to emergency healthcare settings and further demonstrates that nurses′ discretionary practices encompass not only professional and technical judgment but also value-based decision-making and ethical considerations. The findings suggest that health policy implementation is operationalized and contextualized through the professional practices of frontline healthcare workers. From a practical perspective， future institutional design should move beyond an exclusive emphasis on control and supervision toward the development of supportive environments that facilitate appropriate discretionary practice. Through clear authorization， legal protection， organizational support， and adequate staffing arrangements， frontline healthcare professionals can exercise sound professional judgment while maintaining both patient safety and compliance with institutional requirements， thereby enhancing the effectiveness of health policy implementation and strengthening the resilience of the healthcare system.
