Title : Navigating risk and responsibility: Nurses decision-making in implementing the free water protocol for dysphagia care
Abstract:
Background: The Free Water Protocol (FWP) has been increasingly adopted in dysphagia care to improve patient hydration and quality of life. However, its clinical implementation remains complex, as nurses must continuously balance the risk of aspiration against patient-centered benefits. While existing studies have primarily focused on clinical outcomes and protocol efficacy, limited attention has been paid to how nurses make real-time decisions during FWP implementation.
Aim: To explore the clinical decision-making processes of nurses when implementing the Free Water Protocol in dysphagia care.
Methods: A qualitative study was conducted using a constructivist grounded theory approach. Purposive sampling was used to recruit 18 registered nurses from stroke units and rehabilitation settings, all of whom had experience in dysphagia management. Data were collected through semi-structured interviews and analyzed using constant comparative methods, including open, axial, and selective coding.
Results: Nurses' decision-making emerged as a dynamic and context-sensitive process shaped by three interrelated domains. First, risk appraisal involved continuous assessment of patients' swallowing status, alertness, and clinical stability. Second, situational negotiation required nurses to reconcile protocol guidelines with patient preferences, family expectations, and interdisciplinary input. Third, adaptive implementation reflected real-time modifications to FWP practices in response to fluctuating patient conditions and care environments. Across these domains, nurses relied heavily on experiential knowledge to interpret ambiguous clinical cues and to bridge gaps between standardized protocols and individualized care. Notably, decision-making was not a discrete event but an ongoing process embedded within routine care activities.
Conclusion: Implementing the Free Water Protocol extends beyond protocol adherence; it demands complex clinical reasoning and adaptive judgment from nurses. These findings underscore the need to recognize and support nurses' decision-making roles in dysphagia management and to develop implementation strategies that integrate experiential knowledge alongside formal guidelines. Enhancing interdisciplinary communication and decision support may further optimize the safe and patient-centered application of the FWP.
