Barriers and facilitators to implementation of the Free Water Protocol – findings from a national survey of acute stroke unit staff

The Free Water Protocol (FWP) offers patients who are at risk of aspiration with thin fluids the option to drink water under controlled conditions to enhance quality of life and hydration while minimising respiratory complications. Research supports its use in selected patients in rehabilitation settings, however evidence in acute stroke is limited. This study aimed to investigate the barriers and facilitators to the FWP implementation from the perspectives of professionals working in acute stroke units in the United Kingdom to inform a future feasibility study. A national web-based survey was undertaken of acute stroke unit staff, including speech and language pathologists, nurses, doctors, dietitians, and support staff. The survey, informed by the Consolidated Framework for Implementation Research, explored perceived barriers and facilitators towards the FWP implementation. Responses (N = 171) highlighted key barriers such as concerns around risks of aspiration and chest infections, complexity of patient selection, training challenges, oral hygiene practices, high workload, staffing levels and high turnover of staff disrupting implementation, and lack of clinical guidelines and clear governance. Facilitators included supporting evidence, perceived patient benefits, strong multidisciplinary team (MDT) collaboration, leadership by senior clinicians, effective communication, and adaptability of the FWP specifically patient selection and delivery methods among the FWP users. Successful FWP implementation in acute stroke units depends on overcoming risk aversion, strengthening MDT working, enhancing education and training, and embedding robust mouthcare protocols. These findings will guide stakeholder workshops to codesign an implementation strategy for a feasibility study in an acute stroke unit setting.