The devices exist, the evidence is clear — so why does usage remain so inconsistent? A qualitative study identifies the real barriers and concrete solutions.
🎯 Key Takeaways
- Chest compression feedback devices (CCFDs) improve CPR quality and are recommended by the AHA, but their use in clinical practice remains inconsistent and often abandoned.
- The CPR sensor acts as an emotional buffer: compressing on the puck is perceived as less intrusive than compressing directly on the patient’s chest — an unexpected facilitator never previously described in the literature.
- Audio feedback is perceived as disruptive by rescuers (tunnel vision, auditory fatigue), while visual feedback is preferred and considered informative — but it is not always visible to the right person.
- The most decisive factor for consistent use is not the technology: it is team organization. The formal assignment of a CPR coach role and the integration of the CCFD into local cardiac arrest protocols transforms an underused tool into an essential component of the resuscitation process.
- Clinicians are already questioning the future relevance of current CCFDs in light of the emergence of physiology-guided resuscitation (EtCO₂, invasive arterial pressure).
Introduction
The American Heart Association has recommended them since 2020. The European Resuscitation Council confirmed it in its 2025 guidelines. The evidence shows that chest compression feedback devices (CCFDs) improve compression depth, rate, and recoil, and increase the likelihood of return of spontaneous circulation (ROSC).
And yet, in hospitals and prehospital services, these devices are used inconsistently, sometimes removed mid-resuscitation, and often considered “not necessary” by part of the team. In Germany, a registry analysis of 107,548 out-of-hospital cardiac arrest cases showed that CCFDs were used in only a fraction of cases, despite their availability. In Finland, usage was described as “low and infrequent.”
How can a tool recommended by the world’s two leading resuscitation organizations be so underused? That is the question Hansen and colleagues asked — not with numbers, but by going directly to the clinicians who live this reality every day.
📋 Study Fact Sheet
| Field | Details |
| Reference | Hansen ØM, Ingul CB, Storm BS, Solbakken R. Scand J Trauma Resusc Emerg Med (2026). Article in Press. |
| DOI | 10.1186/s13049-026-01607-3 |
| Study type | Exploratory qualitative study, semi-structured interviews |
| Population | 15 healthcare professionals (4 paramedics, 8 nurses, 2 physicians, 1 emergency medical technician) from 3 Norwegian hospitals and 1 Danish prehospital service |
| Instrument | Reflexive thematic analysis (Braun & Clarke), supported by NVivo 15 |
| Journal | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (impact factor: 2.75, Q1) |
| Funding | Open Access by Nord University. No conflicts of interest. |
| Reporting | COREQ checklist |
| Retraction Watch check | No retractions identified |
Methodology
Design: Exploratory qualitative study adopting a pragmatic philosophical stance, in which knowledge is actively constructed through the exploration of lived experience. Semi-structured interviews were conducted by ØMH (critical care nurse and certified ALS instructor) via Microsoft Teams, from December 2024 to February 2025.
Participants:
| Characteristic | Data |
| Number | 15 (10 in-hospital, 5 prehospital) |
| Gender | 7 women, 8 men |
| Median age | 37 years (range 30–59) |
| Median clinical experience | 10 years (range 2–34) |
| Professions | 4 paramedics, 1 emergency medical technician, 2 physicians, 8 nurses |
| Annual participation in resuscitations | 0–5 (n=4), 5–10 (n=6), 10–15 (n=2), 15–20 (n=3) |
| ALS instructors | 4 participants |
Devices used: All CCFDs came from ZOLL Medical Corporation. Prehospital settings used the ZOLL X Series with CPR Stat-Padz electrodes, and hospital settings used the ZOLL R Series with OneStep electrodes. The CPR sensor was integrated into the anterior defibrillation electrode.
Analysis: Reflexive thematic analysis in 6 phases according to Braun and Clarke (2019), involving all 4 researchers. The final dataset comprised 90,589 words of transcripts.
Quality assessment tool: CASP Qualitative Checklist, reporting according to COREQ.
Results
The analysis revealed 4 interconnected themes that capture the facilitators and barriers to CCFD use in advanced clinical practice.
Theme 1: The CPR Sensor — A Key Physical Interaction Point
The sensor is the only point of physical contact between the rescuer and the device. Its ergonomics largely determine the overall perception of the CCFD.
Facilitators: Participants found compressions more comfortable with the sensor, which provides a light cushion, reduces the angle between the hand and the chest, and promotes proper hand positioning. Most notably, the sensor acted as an “emotional buffer” — compressing on the sensor rather than directly on the patient’s skin reduced the emotional discomfort related to the feeling of physical intrusion.
“Even after all these years, I still find it deeply unpleasant to compress directly on a patient’s chest. It feels transgressive […] it’s not nearly as invasive when you have the puck in between.” (Participant 13)
Barriers: The sensor frequently shifted on diaphoretic patients or when the rescuer changed position. Repositioning compromised its adhesive qualities. In one department, prioritizing sensor placement led to suboptimal positioning of the defibrillation electrodes. Misplaced or detached sensors caused frustration and were often removed, rendering the CCFD unusable.
Theme 2: Feedback — Device-Rescuer Communication
CCFD feedback functioned simultaneously as a facilitator and a barrier, depending on its modality.
Visual feedback (facilitator): Generally considered informative, easy to follow, and non-disruptive. Even untrained first responders could be guided by the defibrillator screen to maintain quality compressions.
“We said: ‘You can see how deep you are compressing here.’ Then I noticed that he was like: Okay, fine, now I can… Now I can see what I’m doing, and what I need to do, and I get feedback.” (Participant 11)
Audio feedback (barrier): Rescuers performing compressions often developed “tunnel vision,” reducing their ability to perceive auditory signals. The sound volume was perceived as excessive by other team members, disrupting communication and creating additional stress.
“The feedback volume was hysterically loud — like level 10. It really stressed people out. It doesn’t matter if you see the value in using the device; it’s not a useful tool if it hurts your ears.” (Unidentified participant)
“…the anesthesiologist said: ‘We need to change the defibrillator. This one is driving me crazy.’ It was constantly talking, and that’s not necessary.” (Participant 8)
In some cases, disruptive audio feedback led to complete removal of the sensor or the use of electrodes without a CPR sensor — eliminating both the barrier AND the benefits of the device.
Theme 3: The Organization of Cardiac Arrest Care
The most decisive factor for consistent CCFD use was not the technology itself, but the way the resuscitation team was structured.
Effective model (2 of 3 hospitals + prehospital service): The cardiac arrest team operated as two sub-teams: a clinical sub-team (led by the physician, clinical decisions) and a CPR sub-team (led by a CPR coach or paramedic in zone 3, responsible for compression quality, ventilation, defibrillation, and the ALS algorithm). This CPR coach had formal responsibility for compression quality and CCFD use, creating a sense of ownership and accountability. The local protocol defined a fixed defibrillator position relative to the patient, ensuring that visual feedback was visible to both the rescuer and the coach.
Ineffective model (1 of 3 hospitals): The team operated as a single unit. No member had specific responsibility for compression quality. The team-leader physician was considered “ultimately responsible” but was too busy with clinical decisions to monitor CPR. Responsibility for compression quality was “diffuse and implicitly shared.” The local protocol defined neither mandatory CCFD use nor defibrillator positioning. Result: the defibrillator was sometimes placed so that only the operator could see the screen, electrodes without a CPR sensor were sometimes used, and no one felt responsible for compression quality.
“No, there isn’t anyone dedicated to that, no. There is the team leader, of course — the cardiologist. Although, they use their capacity to find reversible causes…” (Participant 2)
Theme 4: Perceived Usefulness — An Important Facilitating Factor
The perception of CCFD usefulness varied according to the professional’s role during resuscitation.
As CPR coach/supervisor: Real-time feedback was highly valued. Access to objective performance data (depth, rate) supported a more accurate assessment of compression quality. The CCFD also enabled access to complementary defibrillator functions (filtered ECG, algorithm timer), facilitating rhythm assessment and team coordination.
As rescuer performing compressions: Real-time feedback was less valued. Participants relied more on their personal experience and subjective assessment of quality. This difference may be explained by the high cognitive load related to performing compressions and by physical fatigue.
Questioning future relevance: Several participants had already been guided to adjust the compression position based on physiological parameters (EtCO₂, invasive arterial pressure). They considered that individualizing compressions according to physiological response could improve outcomes, and questioned the future relevance of current CCFDs that do not support this approach.
Strengths
- Fills a gap identified by ILCOR: Qualitative research on facilitators and barriers to CCFD use in advanced clinical practice was virtually nonexistent. Existing studies were primarily quantitative.
- Diversity of contexts and professions: In-hospital and prehospital settings, 4 institutions, 4 different professions. Maximum-variation sampling strengthens transferability.
- Methodological rigor: Compliance with the COREQ checklist, Lincoln and Guba’s trustworthiness criteria, reflexive thematic analysis involving 4 researchers from complementary backgrounds (critical care nurse, anesthesiologist-cardiologist, anesthesiologist-quantitative researcher, nurse-qualitative researcher).
- Novel finding: The role of the sensor as an emotional buffer had never been described in the literature — a potentially important facilitator for design and training.
- Direct clinical relevance: The themes identified lead to concrete and actionable recommendations (CPR coach role, defibrillator positioning, local protocols).
Limitations
- Small sample and limited geographical context (selection bias). 15 participants from Norway and Denmark, all experienced. The perspectives of novice clinicians, healthcare systems with limited resources, or non-Scandinavian contexts are not represented. However, information power is a recognized methodological criterion in qualitative research, and the authors justify their sample.
- Single CCFD manufacturer (device bias). All participants used ZOLL devices. Experiences could differ with other manufacturers (Philips, Stryker/Physio-Control, Laerdal) whose sensors, feedback modalities, and integration with the defibrillator vary considerably. The generalizability of the results to other systems is uncertain.
- Absence of member checking. Consistent with Braun and Clarke’s methodology, transcripts and analysis were not returned to participants for validation. Although this approach is consistent with the chosen epistemological stance (the interpretive role of the researcher prevails), it limits verification of the fidelity of the interpretations.
- Digital interviews (observation bias). Interviews via Microsoft Teams limit the ability to observe body language. The authors acknowledge this limitation but argue that the digital format may have increased participant comfort and openness.
- No quantification of described phenomena. The study does not allow determining the frequency or prevalence of the identified facilitators and barriers. We do not know, for example, what proportion of resuscitations is affected by sensor removal or audio feedback disruption.
Discussion
What the study shows. Successful implementation of CCFDs does not depend solely on the available technology — it depends fundamentally on how the resuscitation team is organized. The two-sub-team structure with a formal CPR coach role appears to be the most powerful facilitator for consistent and effective device use.
Why it matters. Hospitals invest in defibrillators with integrated CPR sensors, but without the organizational conditions necessary for these devices to actually be used. This study shows that technological investment is insufficient without organizational investment: defined roles, explicit protocols, standardized equipment positioning.
What could be misinterpreted. It would be wrong to conclude that CCFDs are useless or that audio feedback should be systematically disabled. Evidence suggests that combined audio-visual feedback is more effective than visual feedback alone for patient outcomes. The challenge is to find a balance between the amount of information delivered and team disruption — possibly by directing different feedback modalities to different team members.
What the study cannot conclude. The clinical impact of identified barriers cannot be quantified. The study does not measure whether hospitals with a sub-team structure and CPR coach achieve better patient outcomes than those without this structure. The causal link between team organization, CCFD use, CPR quality, and survival remains to be demonstrated.
Canadian perspective and link to SCORE. The challenges described in this study are exactly those observed in Canadian hospitals. The SCORE program incorporates precisely this logic: compression quality is a fundamental pillar, and team coordination — including a dedicated role for CPR quality supervision — is essential to transform technological availability into actual clinical use. The CPR coach concept described in this study is directly aligned with SCORE’s principles. Hansen et al.’s recommendations constitute a practical roadmap for hospitals that already own CCFDs but are not exploiting them to their full potential.
Authors’ Conclusion
“This study identified key enablers and barriers to the use of chest compression feedback devices in advanced life support. Usability of the CPR sensor, clarity of feedback, and team organization emerged as critical factors influencing both implementation and sustained use. […] Successful implementation of chest compression feedback devices requires user-centered design, role-sensitive feedback modalities, and context-specific protocols.” (p. 32)
Our Conclusion
This qualitative study is exactly the kind of research the field needed. We have known for years that CCFDs improve CPR quality. We know the AHA recommends them. But we continued to observe a massive gap between the recommendation and practice. Hansen and colleagues finally provide concrete explanations grounded in the lived experience of clinicians.
The most striking and probably most actionable finding is the importance of team structure. It is not the device that makes the difference — it is the fact that a specific person is responsible for compression quality and has the tools to fulfill that role. Without this structure, the CCFD is a wasted investment.
In light of these data, here is what I would do in practice today:
- I would formalize the CPR coach role in the cardiac arrest protocol of every unit, with explicit responsibility for monitoring compression quality via the CCFD.
- I would standardize defibrillator positioning relative to the patient to ensure that the feedback screen is visible to both the CPR coach and the rescuer.
- I would reduce audio feedback volume or explore visual feedback configurations directed to the coach rather than broadcast to the entire team.
- I would integrate CCFD use into simulation training, specifically including scenarios where the CPR coach uses device data to guide the team.
The discovery of the sensor’s “emotional buffer” role is fascinating and deserves further exploration. If the sensor helps rescuers maintain focus by reducing emotional discomfort, that is an additional argument for its systematic use — an argument that speaks to the lived experience of clinicians, not just to quality metrics.
💊 Clinical Bottom Line
CCFDs improve CPR quality, but their use in practice depends on specific organizational conditions: a formal CPR coach role, standardized defibrillator positioning, and local protocols that explicitly integrate the device. Visual feedback is preferred and informative; audio feedback is often disruptive and may lead to device removal. For every dollar invested in technology, invest a dollar in team organization.
Statistical Legend
As this is a qualitative study, it does not report traditional inferential statistics. Here are the key methodological terms:
- Reflexive thematic analysis (Braun & Clarke): A 6-phase qualitative analysis method (familiarization, coding, theme construction, review, definition, writing) in which the researcher plays an active role in constructing meaning from the data. Unlike “codebook” thematic analysis, it does not aim for inter-coder consensus but for reflexive depth.
- Information power: Concept proposed by Malterud et al. (2016) to guide sample size in qualitative research. Rather than a fixed threshold (such as “saturation”), it considers the adequacy of information based on the study aim, participant specificity, underlying theory, dialogue quality, and analysis strategy.
- COREQ (Consolidated criteria for Reporting Qualitative research): A 32-item checklist ensuring transparency in qualitative research reporting, covering the research team, design, and analysis.
- Maximum-variation sampling: A recruitment strategy aimed at including participants with varied characteristics to capture a broad range of experiences and identify shared meanings across contexts.