Iran Journal of Nursing

1. Introduction
Cardiopulmonary resuscitation is one of the most important medical emergencies. The positive effect of trained and skilled people on the outcome of resuscitation has already been proven. However, the studies indicate poor performance and insufficient knowledge of operating room technicians in cardiopulmonary resuscitation. Despite the importance of cardiopulmonary resuscitation training, very little attention has been paid to teaching patients' life skills using attractive and appropriate methods. So the current need is not only to increase cardiopulmonary resuscitation training but, more importantly, to increase the quality of training. One way is self-assessment. In the medical profession, the ability of employees to identify their strengths and weaknesses is essential, and proper self-assessment can be effective in developing a person's abilities. Learners also use the rethinking process to gain insight into their performance and identify strengths and abilities, as well as areas that may require further development (weaknesses). This study aimed to investigate the effect of visual self-assessment training on the level of knowledge, self-esteem, and performance of operating room personnel when learning advanced cardiopulmonary resuscitation.
2. Materials and Methods
This quasi-experimental has a pretest-posttest single group design. A total of 32 operating room technicians participated in this study. According to the inclusion criteria, the available method sampling was continued until reaching the specified sample size. The intervention was a cardiopulmonary resuscitation workshop and takes a video from resuscitation operation on the model by each of the participants and then replays the video for self-assessment. The 2-day workshop includes theoretical and practical training, including recognizing life-threatening dysrhythmias, recognizing and using the cardiac shock device, airway management (airway opening maneuvers and artificial respiration by airway and ambo bag), and cardiopulmonary resuscitation training. According to the latest guideline of cardiopulmonary resuscitation (2017), this training was in the form of a lecture and slide show. The resuscitation steps were performed in simulations on a mannequin for cardiopulmonary resuscitation. At the end of the workshop on the second day, each participant was given 3 minutes to perform a short-term scenario about cardiopulmonary resuscitation. All participants' performances were recorded, and then each person's video was shown to him or her on the TV in the resuscitation room. Then, knowledge, self-esteem questionnaire, and self-assessment performance checklist were given to each participant to complete immediately after the intervention. During the resuscitation by the participants, a performance observation checklist was completed for them by the researcher. Then, 8 weeks after the intervention, the participants repeated the above steps by receiving another short scenario and performing 3 minutes of cardiac resuscitation on the mannequin, showing the resuscitation video, and completing the knowledge, self-esteem, and self-assessment questionnaire. The researcher again completed the performance observation checklist for each participant. So the data were collected using a researcher-made questionnaire and Rosenberg self-esteem questionnaire three times (before, immediately, and 8 weeks after the intervention). Also, a self-assessment performance questionnaire and observational performance checklist were completed two times (immediately and 8 weeks after Intervention). This article was extracted from a research project approved by Isfahan University of Medical Sciences, Isfahan City, Iran. During the research process, the ethical principles of the university were observed, including obtaining informed consent from the technicians. The obtained data were analyzed by repeated-measures analysis, Greenhouse-Geisser and Bonferroni post hoc test, and paired t-test in SPSS version 16. 
3. Results
A total of 32 operating room technicians were initially included in the study. One participant was excluded due to obstetric delivery, one due to transfer from a medical center, and 2 due to not participating in the evaluation 8 weeks after the intervention. Finally, data analysis was performed on 28 operating room personnel. Demographic data of participants showed that 89.29% of them were female, 67.86% had a bachelor's degree in operating room, and the mean age of participants was 39.37 years. The differences in the mean score of operating room technicians' knowledge in 3 time points were significant (P<0.001). The pairwise comparison of knowledge index was significant at before-immediately after (P<0.002) and before-8 weeks after the intervention (P<0.05). The comparison of the mean score of operating room technicians' self-esteem in 3 times was significant (P<0.001). Also, the comparison of the mean performance self-assessment score and the mean performance score observed immediately after and 8 weeks later was significant (P<0.001). According to the Bonferroni test results of the knowledge index in pairs at three different time points, the differences between the means of the time points of before and immediately after the intervention and the time points of immediately after and 8 weeks after the intervention were significant (P<0.0001). But, there is no significant difference between the time points of before and 8 weeks after the intervention (P=0.321). Also, according to the results obtained by comparing the self-esteem index in three different times, the differences between the means of the time points before and immediately after the intervention (P=0.002) and the time before and 8 weeks after the intervention was significantly different (P=0.05). However, there was no significant difference between the time points of immediately after and 8 weeks after the intervention (P=1.000). So visual self-assessment had increased the self-esteem of operating room technicians in cardiopulmonary resuscitation, and it remained high 8 weeks later. However, the knowledge index was elevated immediately after the intervention and decreased significantly 8 weeks after the intervention. There was also a significant improvement in functional cardiopulmonary resuscitation.
4. Conclusion
Visual self-assessment method had effectively increased the knowledge, self-esteem, and performance of operating room technicians in the field of cardiopulmonary resuscitation. Especially since their self-esteem and performance will be indelible. The presentation of this method by clinical instructors and diversity in educational affairs are the advantages of using the visual self-assessment training method in clinical education. This method can be helpful if its outputs, such as quality of patient care, will be evaluated. It is suggested that such a study be conducted in other research settings and investigate factors affecting the self-esteem and performance of staff and even their self-efficacy and self-confidence to perform care, especially in emergencies.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Research Ethics Committee of Isfahan University of Medical Sciences (Code: IR.MUI.RESEARCH.REC.1398.390). All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information. They were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This study was supprted by the Isfahan University of Medical Sciences (No.: 198087). 

Authors' contributions
Conceptualization and methodology: Amir Azadi and Narges Khairollahi; Research, study and implementation: Nasrollah Ali Mohammadi, Amir Azadi, Zarrin Tansaz and Narges Khairollahi; Editing and finalizing: Sorour Mosleh.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We want to thank the Operating Room Technicians for their help.


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