在多重制度壓力下的創新：公立醫院住院友善共聘制度正當性建構歷程

Innovation under Multiple Institutional Pressures: The Legitimacy Construction Process of a Friendly Co-Employment System for Inpatient Care in Public Hospitals

目的：為因應台灣高齡化社會與護理人力短缺挑戰，政府自2017年起推動「住院友善共聘制度」，以整合照護人力並提升住院照護品質。本研究探討公立醫院在多重制度壓力下導入共聘制度之正當性建構與制度化歷程，分析制度內化機制。方法：採單一個案研究，以某公立區域教學醫院（以下簡稱某公立醫院）為研究場域（2018—2023年），蒐集參與式觀察、政策與會議紀錄及次級資料，並深度訪談10位關鍵行動者，透過主題分析重建制度推動脈絡。結果：制度導入歷程可分為四個階段：定義期（高層政策倡議與正當性建構）、推動期（中階管理者之跨部門轉譯與協調）、標準化期（制度流程內化），以及策略化期（制度再詮釋並整合進組織文化）。進而形構「制度正當性堆疊與回饋循環模型」，呈現強制性、模仿性與規範性同形壓力之動態互動。結論：共聘制度成功推動須兼顧外部合法性與內部行動策略，透過中階管理者轉譯與跨層級協作，促成制度由政策倡議內化為組織常態化，作為公共醫療制度創新的實證參考。

Objectives. To address the challenges of population aging and nursing workforce shortages in Taiwan, the government launched the Inpatient-Friendly Joint Employment Program in 2017 to integrate care manpower and enhance the quality of inpatient care. This study examines the construction of legitimacy and the institutionalization process of implementing the program in a public hospital under multiple institutional pressures, focusing on the mechanisms of legitimacy building and internalization.
Methods. A single-case study design was adopted using a de-identified public teaching hospital as the research setting, covering the period from 2018 to 2023. Data were collected through participatory observation, policy and meeting documents, secondary sources, and in-depth interviews with ten key stakeholders. Data analysis continued until thematic saturation and employed thematic analysis to reconstruct the contextual process of institutional implementation.
Results. The implementation process was categorized into four phases: the defining phase (top management's policy advocacy and legitimacy construction), the promoting phase (middle managers' cross-departmental translation and coordination), the standardizing phase(process internalization), and the strategizing phase (institutional reinterpretation and in-tegration into organizational culture). These phases collectively form a 'Legitimacy Stacking and Feedback Loop Model,' illustrating the dynamic interactions among coercive, mimetic, and normative isomorphic pressures.
Conclusion. Successful innovation and implementation of the joint employment system require balancing external legitimacy with internal strategic actions. Institutionalization is achieved through middle managers' translation and cross-level collaboration, facilitating the transformation from policy advocacy to organizational normalization. The findings provide practical insights for public healthcare policy implementation and inform future research.