PBL facilitator training focusing on the skills of promoting student critical thinking


 Background Critical thinking is an essential skill for medical graduates. The aim of the following study is to train the facilitators to boost critical thinking during the PBL sessions. Method Forty PBL facilitators of the college of Medicine, the year 2019-2020, were invited to fill a questionnaire and participate in a workshop. The questionnaire measures the background knowledge of the facilitators about critical thinking. The workshop started with a presentation then followed by exercises to apply different techniques for critical thinking. Results Most of the facilitators (>80%) believe that PBL supports critical thinking. > 50% are using questioning technique. None were aware of any other technique. Following the workshop, > 50% were able to suggest other relevant techniques such as debate, hypothesis and role play. Most of the facilitators admired the activity and requested similar training sessions. Conclusion Facilitators training workshop needs to be tailored toward specific PBL outcomes. Critical thinking is one of the most important targets of PBL. However, facilitators of previous facilitation experience and exposure to general PBL workshops lack the skills to support critical thinking. The currently focused workshop yields promising reflection by the participants' feedback and performance.

In the college of medicine, Imam Abdulrahman Bin Faisal university, Dammam, Saudi Arabia an integrated problem-based learning curriculum was launched in 2014. Tutor training was one of the most important concerns. A program of regular workshops was established. An anticipatory workshop at the start of each semester was planned. The workshops were organized to deliver a holistic training toward the whole PBL process, or a speci c session targeting the training toward one learning outcome. In the current study, we have planned a training session aimed to explore the background of the tutors in regard the impact of PBL on promoting critical thinking, investigate their current practice, discuss some techniques to provoke critical thinking and provide them with training opportunity through exercises to apply these multiple techniques.

Methods
The current work and study were approved by the deanship of college of medicine, and received ethical approval from the institutional ethical committee of deanship of scienti c research in Imam Abdulrahman Bin Faisal University with ethical number (2019-01-293).
Forty faculty members from the college of medicine, who participated in PBL facilitation in the rst semester, academic year 2019-2020 were invited to participate in the study and requested to ll a study consent. A questionnaire was sent to those who submit their consent. The questionnaire included two set of questions, one is related to the basic data such as age, gender, duration of experience in PBL facilitation, and number of PBL workshops attended. The second included questions related to the role of PBL in developing critical thinking, some are in the form of open-ended question and others in 5-Likert scale (Table 1). The structure and design of the problem is an important factor in promoting students' critical thinking The student internal motivation and academic achievement is important in the development of critical thinking The facilitator role is important in promoting student critical thinking The facilitator role in probing questions during the PBL session fosters the development of student critical thinking The facilitator role in giving shortexplanatory notes during the PBL session is important in promoting student critical thinking The facilitator role in encouraging a wellorganized debate is important in promoting student critical thinking 2 (6%) 3 (9%) 8 (26%)

(39%)
The facilitator role in encouraging the student to propose a hypothesis and search for evidence is important in promoting student critical thinking 2 (6%) 2 (6%) 11 (35%)

(52%)
During the day of the workshop 15 minutes presentation was delivered. It includes an introduction of the signi cance of critical thinking as an outcome for the modern curricula. The role of the PBL in promoting critical thinking was highlighted through presenting positive and negative ndings of international researchers and educationist. The factors that might in uence the effectiveness of PBL program were discussed. The signi cance of tutor training was emphasized and particularly in relation to the enhancement of student critical thinking. Multiple pertinent pedagogical techniques that can be practiced by the tutor during the PBL session was introduced. These techniques were recommended in order to foster the development of critical thinking of the students. The presentation was concluded actively, by sharing a group of clinical scenarios (short problems), and the audience were requested to propose the most relevant technique. Last part of the workshop included an individual-based exercise. Each candidate was asked to select the most relevant pedagogical techniques among six listed techniques for four examples of problems (Appendix 1).
All the attendants were asked to report their evaluation of the workshop.
Data were analyzed using SPSS version 24. Correlation was assessed using Pearson correlation. A signi cant level was considered when P-value is < 0.05.

Results
Among the forty invited PBL facilitators, 31 responses were received. 48% (15) of the participants were male, and 52% (16) females. The age ranges from 30-65 with an average of 45 years old. The academic rank includes 3 lecturer, 21 assistant professor, 6 associate professor, and one professor. Twenty-nine are medical graduates with MBBS degree and two with science background. Subspecialties include physiology (12), anatomy (7), biochemistry (3), Family and community medicine (4), Microbiology (2), pharmacology (1), pathology (1), and general surgery (1). Number of years of participating in PBL facilitation ranges from 1 to 6 years with an average of 3.5 years. Number of PBL training workshop ranges from 1-8 with an average of 2.6 (mode = 1, median = 2). All the questionnaire responses are summarized in Table 1. Answers to the opened question: "What are the techniques used by the tutor to promote student critical thinking" are presented in Table 2. Methods used by the tutor to assess the students critical thinking are presented in Table 3. The participants' response to the workshop exercise is presented in Table 4. By the end of the activity, all participants demonstrated positive attitude toward the workshop, they described the activity as focused, well designed and addressing an important concept. Furthermore, they admired the concept of tutor training toward a speci c objective such as critical thinking. They manifested preference of training sessions toward each speci c objective of the PBL. General training workshops might overlook some of the essential elements and objectives expected from PBL teaching. Encouraging discussion and brain storming 12 Promoting the generation of ideas and hypothesis 1 Linking to their previous knowledge 1 Encouraging the use of drawings and diagrams 1

Discussion
Critical thinking is an essential competency for medical graduates [10]. Medical curricula must be welldesigned and well-equipped with teaching opportunities that promote critical thinking [11]. Evidences from the literature supported that critical thinking can be systematically taught. Most educators encouraged teaching critical thinking in context that provide a medium of integration of multiple source of knowledge.
The learners are advised to explore all related information, and possible solutions or decisions, avoid cognitive bias and premature closure of discussion [12,13].
One of the most widely used pedagogical method to promote critical thinking is problem-based learning PBL [14]. PBL is widely used by the medical schools. The in uence of PBL on the development of student critical thinking was the concern of many educators. Several studies using a variety of tools to measure the impact of PBL on student critical thinking have been identi ed [15]. At the University of Hong Kong, 79 rst year undergraduate students were randomly assigned to either traditional lecturing method or PBL.
The critical thinking disposition was measured by California Critical Thinking Disposition Inventory (CCTDI) in 4 timepoints and student perception of their learning experience by individual interviews. PBL group demonstrated a signi cant improvement in CCTDI as compared to their counterparts of the traditional teaching and to their scores at the start point. In addition, the students' perception toward the experience was positive [16]. In a study in china, 102 third year medical students at Perking University, were tested for their critical thinking disposition using CCTDI and PBL evaluation forms. All the students showed positive scores in CCTDI with an average of 297.72. CCTDI score showed also positive correlation with the PBL evaluation scores [17]. Furthermore, the performance of 193 medical students at Al Nafees medical school, Islamabad, Pakistan in a higher cognitive and clinical reasoning exam was improved after one-year PBL program [18]. However, some practices showed discouraging ndings in regard the effect of PBL in the domain of higher cognitive function and critical thinking. Using CCTDI to test the critical thinking disposition in 76 undergraduate students before and after the exposure to PBL teaching revealed no signi cant difference in their scores [19]. Although PBL is recognized as a good medium to nurture student critical thinking. This teaching opportunity needs extensive collaborative and coordinated efforts to ensure the quality of the problem scenarios, the skills and enthusiasm of the tutors, the readiness of the students and the alignment with the learning environment [20].
In the current study, we focused on the tutor training as an important element toward the success of PBL in nurturing critical thinking. We aimed to explore the background of the PBL tutors and their awareness of the role of PBL in promoting student critical thinking, as well as train them to utilize multiple techniques during the PBL session to elicit critical thinking.
The participated PBL tutors have been exposed to several PBL workshops and practicing PBL facilitation for up to 6 years. Most of them (above 80%) agreed toward the role of PBL in promoting critical thinking. More than 80% believe that the structure and design of the problem, the tutor skills and the student selfmotivation and academic achievement have a signi cant impact on the development of student critical thinking. Probing questions and encouraging discussion was the most used method by the tutors. Although most of them agreed that other methods such as debate, role play and framing a hypothesis can be used in PBL sessions to promote critical thinking, none of them propose these methods in the open-ended question. More than 30% disagreed regarding the effectiveness of role play in promoting critical thinking and 64% accept giving short explanatory notes (mini lecturing) during the PBL sessions. The duration of practicing PBL facilitation, seniority, or number of attended PBL workshops did not re ect better practices or responses. Speci c training that targeted the improvement of tutor skills toward individual PBL learning objectives is essential [21,22]. In the current study, the tutors were trained speci cally to utilizes different techniques during the PBL sessions in order to foster the student critical thinking. The tutors have enjoyed the activity and were interested to learn these different techniques including; questioning, linking to previous knowledge, using concept mapping, formulating hypothesis, debate, and role play. They re ected positively on the relevance of these techniques to different clinical inquiries and their impact on the dynamic of the PBL session. Utilizing a variety of techniques during facilitating PBL ensures successful interaction, and deep learning. It also maintains fruitful interesting atmosphere [23]. Majority of the tutors (> 50%) were able to suggest the most relevant technique per scenario during the activity session. Most of the tutors requested similar workshops in the future. Further follow up and reinforcement of the implementation of these techniques in the PBL sessions is recommended. Student feedback can be sought to explore the impact of this workshop on the tutor performance, and in speci c toward utilization of different techniques to inculcate critical thinking.

Conclusions
Realizing that the tutor skills and training is an important element for the success of PBL teaching. Specialized training workshop that target each expected PBL outcome is essential to address the importance of that outcome, and to provide the tutor with multiple practical tools and techniques. Critical thinking is one of the main outcomes of PBL teaching. It can be augmented by a skillful tutor who motivate the students by different techniques such as probing questions, linking to previous knowledge, debate, role play, and synthesizing hypothesis. The current study re ects a successful design of specialized PBL-tutor workshop as perceived by the participants' feedback and their performance. All participants submit an electronic written consent.

Consent for publication
Not applicable

Competing interests
The author has no con ict of interest.

Funding
There was no fund for the current work.

Availability of data and materials
All Data are available with the author and can be provided upon request.
Authors' contributions LIA is the sole author of this manuscript. LIA is responsible for conceptualization, design, data collection and manuscript writing. LIA has read and approved the manuscript.