Publish at April 09 2025 Updated April 09 2025
Therapeutic patient education (TPE) is playing an increasingly important role in the management of chronic diseases. Defined as a continuous, patient-centered process, integrated into care, TPE aims to help patients acquire or maintain the skills they need to manage their lives with a chronic disease. Numerous studies have demonstrated the benefits of ETP in terms of improved quality of life, therapeutic compliance and reduced complications and recourse to care.
However, it has to be said that training in TVE for healthcare professionals is still limited. Although TVE training courses have developed in recent years, they are still insufficiently integrated into the initial curricula of healthcare professionals. Programs are often theoretical, not geared to the acquisition of practical skills, and do not sufficiently address the educational posture required in the caregiver-patient relationship.
It was against this backdrop that the Service Sanitaire des Étudiants en Santé (SESA) (Health service of health students) was introduced at the start of the 2018 academic year. Introduced by decree no. 2018-472 of June 12, 2018(1), this scheme provides for all health students to carry out interventions devoted to prevention and health promotion, within a host structure, during their training. The stated aim is to enable students to carry out concrete preventive actions with a variety of target groups, and to train future healthcare professionals in their role as preventive actors.
Although the SESA is not specifically dedicated to TVE, it is nonetheless an interesting opportunity for students to develop skills useful in patient education. By bringing them face-to-face with a variety of publics, giving them the opportunity to experiment with actions in the field, and introducing them to a project-based approach to education and prevention, the health service can help to anchor a genuine culture of therapeutic education in future caregivers.
However, SESA is no substitute for in-depth training in TPE. It must be designed in conjunction with the theoretical training provided throughout the course, as part of a continuum of education. It also requires greater support from teaching teams and close links with internship sites and professionals in the field.
This article explores how the SESA can be a lever for training healthcare students in therapeutic patient education. After outlining the main principles of this system, we will analyze its potential contribution to the development of TPE skills. We will then look at how the SESA can be linked to theoretical training, through the testimonies of students and trainers. Finally, we'll suggest ways in which the health service can be developed to optimize its pedagogical benefits.
This report is based on my experience as a trainer at a paramedical training institute, my discussions with students who have completed their SESA and a review of the literature on the subject. Its aim is to stimulate collective reflection on TVE training, its challenges and possible levers for improvement.
The Service Sanitaire des Étudiants en Santé was instituted by Decree no. 2018-472 of June 12, 2018(1), which sets out the terms and conditions for its organization and validation.
This scheme is aimed at all health students: medicine, odontology, pharmacy, maieutics, physiotherapy and nursing. It is designed to be carried out in an interprofessional context, to encourage decompartmentalization between different disciplines. Lasting a total of 6 weeks on a full-time basis, it can be carried out on a continuous or split basis, during the first cycle of studies (between years 2 and 6, depending on the field).
The SESA has a dual objective:
The texts stipulate that the actions carried out by students must focus on priority public health themes: nutrition, physical activity, addictions, sexual health, mental health, etc. They must be targeted primarily at the general public. They must be aimed primarily at people who are far removed from the healthcare system, or in precarious situations, in order to help reduce social and territorial inequalities in health.
One of the major assets of the SESA program is the opportunity it gives students to immerse themselves in the populations they will be called upon to care for once they graduate. This early exposure to the realities of the field is essential for developing interpersonal skills and an awareness of the social determinants of health.(2)
SESA internship sites are highly diversified and complement hospital internship sites: schools, neighborhood associations, young workers' hostels, social centers, residential facilities for dependent elderly people (Ehpad), migrant support structures, etc. This variety enables students to discover a wide range of publics and healthcare issues.
During their internships, students are encouraged to forge partnerships with various organizations (local authorities, associations, medical-social establishments, etc.) and to work in collaboration with professionals from a wide variety of fields (education, social work, entertainment, medical-social work, etc.). This partnership and inter-professional dynamic is an asset in understanding the complexity of public health issues. It prepares future healthcare professionals to take a regional, decompartmentalized approach to their work.
During their health service, students are required to design and implement primary prevention and health promotion initiatives. This may take the form of educational sessions in schools, awareness-raising workshops, discussion sessions with specific populations, development of prevention materials, organization of events such as health forums, etc. Whatever form they take, these actions are designed to promote health and well-being.
Whatever form they take, these initiatives must meet three imperatives:
Through these requirements, SESA aims to introduce students to a health promotion approach that is not limited to the dissemination of top-down health messages, but involves co-construction with the target audience. This learning-by-doing approach is essential to anchor the principles and methods of prevention(3).
Confrontation with a variety of audiences also means that students have to adapt their discourse and media to the people they meet. This is an opportunity for them to appreciate the importance of adjusting intervention strategies to take account of each individual's knowledge, representations and aptitudes in terms of health. A requirement that directly echoes the principles of therapeutic patient education.
During their SESA, students interact with audiences who are not in a position to seek care. Whether they're working with teenagers in schools, residents of nursing homes or people living in precarious conditions, they have to address the issue of health outside a traditional healthcare relationship.
This configuration forces students to go beyond a strictly biomedical, top-down approach to health education. They can't simply deliver information or behavioral prescriptions. They must adopt a posture of listening and dialogue, building on the knowledge and questions of their audience, and co-constructing prevention messages.
It's a unique opportunity to experience an educational posture based on empathy, active listening and non-judgment. A posture that lies at the heart of therapeutic patient education. By moving away from a classic caregiver-patient relationship, SESA helps students to understand the patient's uniqueness, needs and resources, rather than focusing solely on his or her pathology.
Exposure to a variety of populations also confronts students with the impact of social and environmental determinants on health. Through contact with vulnerable populations or those far removed from the healthcare system, they become aware of the importance of living and working conditions, level of education, social isolation and other factors in the occurrence and management of health problems(4).
This population-based approach to health(5) echoes one of the skills expected in TVE: the ability of the caregiver to take into account the patient's living context, socio-economic constraints and family environment. This is an essential skill for co-constructing a realistic and appropriate educational project with the patient.
The health service provides students with an opportunity to develop and apply their teaching skills. Confronted with the need to convey preventive messages, they experiment with different intervention methods and media.
This begins with adapting their discourse and popularizing scientific knowledge. Faced with non-specialist audiences, students learn to use a simple, accessible vocabulary, to explain medical concepts without jargon, and to use concrete examples and analogies.
They are also encouraged to develop or appropriate a variety of teaching tools, including visual aids, role-playing, case studies and interactive activities. All of these techniques are designed to make sessions more attractive and participative. By experimenting with the design of tools adapted to different formats (workshops, stands, classroom interventions...) and audiences, students acquire a range of invaluable know-how.
The SESA program is also an opportunity to develop group leadership skills. During group activities, students learn how to create a dynamic exchange of ideas, encourage everyone to speak up and express themselves, and manage interactions. These skills are directly transferable to the animation of ETP sessions, which rely heavily on group discussions.
In addition to these pedagogical skills, SESA helps to forge the interpersonal skills that are essential to any educational approach: the ability to listen and empathize, to manage emotions, to be assertive in communication, and so on. All of these skills help caregivers to establish a relationship of trust with patients, a prerequisite for any TVE project.
One of the common threads running through the health service is raising students' awareness of social and territorial inequalities in health. By working with vulnerable or isolated populations, they discover the impact of living conditions on people's state of health.
This awareness leads them to question their perceptions of the origins of health problems. They realize that individual behavior is largely influenced by social and environmental determinants that are beyond the scope of the medical field alone: economic insecurity, social isolation, low levels of education, poor working or housing conditions...
For future healthcare professionals, it's an opportunity to move beyond a strictly biomedical interpretation of health to a more global approach that takes into account all the dimensions of people's lives. This change of perspective is at the heart of the therapeutic patient education approach.
Indeed, TPE cannot do without considering the patient's living conditions and social environment. To be effective, any educational project must integrate the constraints and resources specific to each patient, whether material, relational or cultural. It's not just a question of transmitting biomedical knowledge, but of supporting the patient in appropriating this knowledge and converting it into skills that can be mobilized in the context of his or her own life(6).
By raising students' awareness of the non-medical determinants of health, SESA helps to change the way they look at patients. It encourages them to detach themselves from a strictly biomedical model, in order to grasp the singularity of each situation. This openness is essential to the practice of therapeutic education.
Although therapeutic patient education has been recognized as a public health priority since the HPST law of 2009(7) , we have to admit that its integration into the initial training of healthcare professionals is still limited and uneven from one training program to another.
Although, since the 2009 reengineering, all nursing training institutes now offer FTE courses, notably as part of UE 4.6, the hourly volume is still too small.
In medical faculties, TVE appears as a training theme, but rarely as a full-fledged course. Its hourly volume, modalities and content vary greatly from one university to another. Most of the time, TVE is dealt with transversally in different modules (public health, doctor-patient relationship, outpatient training, etc.), without being the subject of a dedicated teaching unit.
Other shortcomings in TVE training for future doctors have been identified: a very (bio)medical approach to chronic disease, little awareness of psychosocial determinants, lack of training in pedagogical and relational techniques, lack of practical teaching...
Across the board, the dominant model is still one of prescriptive therapeutic education, often reduced to the transmission of information about the disease and its treatment. The psycho-socio-educational dimensions, the patient-centered approach and teaching methods are insufficiently developed in teaching.
TVE training also suffers from a weak link between academic knowledge and clinical skills. Theoretical content is not sufficiently linked to internships and students' field experience. Conversely, internships rarely include an explicit TVE training objective. As a result, students struggle to make the link between what they've been taught and the educational situations they encounter on placement.
In the light of these observations, the health service appears to be an interesting opportunity to reinforce students' practical training in TVE.(8) By getting them to design and run educational actions with a variety of publics, it enables them to put into practice the theoretical lessons they have learned elsewhere.
Take the example of a medical student who has taken a course on behavior change models in health education. By running smoking prevention workshops with teenagers during his SESA, he will be directly confronted with the brakes and levers that influence health choices. This will enable him to better understand the advantages and limitations of the different models seen in class.
In the same way, a student nurse who has been made aware of the importance of empathy in the healthcare relationship will be able to experience in vivo the techniques of active listening and reformulation during a preventive interview with an isolated elderly person.
By offering students the opportunity to apply their knowledge directly, the SESA encourages the transfer of knowledge and the development of TVE skills.(9) It helps to give meaning and coherence to theoretical teachings by linking them to real-life situations.
However, this contribution can only be effective if SESA experiences are the subject of in-depth pedagogical exploitation. It is essential that internships include time for practical analysis, supervised by the instructors. These sessions should enable students to explain the situations they have encountered, and identify the knowledge they have mobilized and the skills they have developed.
This is where the link with theoretical training comes into its own. By helping students to make the link with course content, trainers promote the gradual integration of the different fields of knowledge (biomedical, relational, pedagogical, etc.) required for the practice of TVE.
While the health service represents an interesting lever for practical training in TVE, its potential can only be fully exploited if students are provided with reinforced pedagogical support.
Even before the internship, it is important to prepare students for the specificities of a health education approach. This involves not only theoretical instruction, but also hands-on experience to familiarize them with leadership techniques, the educational posture and pedagogical tools. Project design workshops can also be offered to guide students in the development of their SESA actions.
During the internship, regular follow-up by the mentor trainers is essential. Over and above the logistical aspects, the aim is to provide genuine pedagogical mentoring, helping students to explain their choices, analyze difficulties encountered and identify what they have learned. On-site visits, group discussions between students and follow-up tools (logbook, self-assessment grid) are all ways of reinforcing this support.
After the internship, debriefing and reflective analysis sessions should be organized to help students conceptualize the skills they have developed. This is an opportunity to deepen the links with theoretical lessons, and to highlight achievements and areas for improvement. The production of an activity report or portfolio can be a useful complement to this reflective approach.
In addition to this formal support, the quality of the pedagogical relationship between trainers and students is essential. By adopting a facilitator's stance, valuing successes as well as mistakes as a source of learning, and encouraging autonomy and creativity, trainers create a climate conducive to skills development.
Enhanced support therefore implies rethinking training engineering and fully recognizing the SESA as a period of professionalization in its own right. This means clarifying pedagogical objectives, earmarking dedicated resources and training teaching teams. These are all conditions that need to be met if the health service is to become a genuine lever for training in TVE.
One of the key challenges in optimizing the pedagogical potential of the SESA is to strengthen student preparation prior to the placement. The aim is to provide them with the methodological and conceptual keys they need to better grasp the educational dimension of their mission.
This begins with theoretical training to acquire basic knowledge of prevention, health education and TVE: key concepts, theoretical models, evidence-based data, etc. The aim is to give students an intellectual "toolbox" for deciphering the complex educational situations with which they will be confronted.
Theoretical input is complemented by practical situations. Through role-playing, simulation workshops and case studies, students can practise animation techniques, adopt an educational posture and manage delicate relational situations. These exercises are essential to gently prepare for the realities of the field.
The preparation phase is also the time to help students structure their SESA project. Project methodology sessions can be organized to guide them step by step: analysis of the request and context, definition of objectives and teaching resources, planning of stages, anticipation of evaluation... These are all milestones that facilitate the transition to action.
This "practical-theoretical" preparation would benefit from being complemented by an awareness of the specific challenges of the territories and audiences concerned by the course. Meetings with local players, testimonials from former students, immersion in the host organization... all help to better decode the realities on the ground and adjust the project accordingly.
One of the keys to making SESA a lever for professionalization is to strengthen collaboration between training institutes and the structures hosting trainees. Far from being mere training grounds, these places are essential partners in the learning process.
This means developing close links between trainers and internship supervisors. Prior to welcoming students, discussions should help clarify the framework and pedagogical expectations of the internship, and define each person's role and missions. In this way, the internship supervisor can better position himself in his role as coach and skills assessor.
During the internship, regular visits by the trainers reinforce this pedagogical partnership. They provide an opportunity to observe students in real-life situations, to discuss their progress and any difficulties they may be experiencing, and to adjust the course if necessary. These meetings are essential to ensure individualized follow-up.
The institute/field link also involves the organization of collective regulation sessions. A forum for exchange between students, trainers and internship supervisors, these sessions enable students to pool their experiences and share their analysis of practices. A way of facilitating the transfer of learning and gradually blurring the boundary between "the field that does" and "the school that says".
Joint training is another way of building bridges. Inviting referents to take part in theoretical courses on TVE, or inviting trainers to co-facilitate educational sessions at the facility, helps create a shared culture. An inter-knowledge conducive to the decompartmentalization of knowledge.
One of the major assets of the SESA program is that it enables students from different disciplines to work together on common projects. This "360°" interprofessional approach is a wonderful opportunity to learn how to work together and discover the added value of each profession in an educational approach.
To reinforce this, it is important to schedule shared training sessions before the internship. Seminars bringing together students from different disciplines can be organized to work on concrete TVE cases, exchange views on each other's representations, and identify possible complementarities. The aim is to lay the foundations of a common culture before launching into action.
During the SESA, trainers can encourage the creation of interprofessional pairs or trinomials at the training site. By entrusting these tandems with the responsibility of designing and running education sessions together, they are helped to experience collaboration in practice. However, local support is needed to facilitate the distribution of roles and manage any tensions that may arise.
Inter-faculty co-development forums can also be set up on a regional scale. By bringing together students from different SESAs on a regular basis, they can share experiences, help each other deal with complex situations and pool resources. Led by trainers from different institutes, these workshops are also a way of strengthening partnerships between establishments.
Students can also take part in interdisciplinary TVE research projects. Accompanied by teacher-researchers from different specialties (medicine, education sciences, sociology, psychology, etc.), they learn to develop a multifocal approach to educational issues, while at the same time learning about field investigation methods.
Strengthening the training potential of SESA also means equipping ourselves with robust tools for assessing the skills developed by our students. Far from a purely summative approach, we need to see assessment as a lever for learning and recognition of experiential achievements.
The first step is to clarify the skills repository in question. Over and above the general objectives of the health service, each institute would do well to define the specific skills required in its field: interpersonal skills, teaching skills, organizational skills, reflexive skills... A detailed reference framework that will serve as a compass for students and trainers alike, enabling them to situate progress.
Various assessment tools can be deployed on the basis of this mapping. The portfolio is an interesting way of encouraging reflective analysis. By recording their experiences, their successes and their difficulties, students learn to put their learning into words and identify their areas for improvement. This exercise is all the more instructive in that it is supported by feedback from trainers.
Observation grids can also be devised to assess students in real-life situations, when they are running TVE sessions. Co-developed with the internship supervisors, they provide a cross-check on the skills demonstrated and help formalize areas for improvement. To support the development of skills, these assessments should be repeated at different stages of the course.
At the end of the internship, original evaluation methods can be devised to showcase the students' achievements. Photo exhibitions, forum theater sketches, moving debates... are just some of the entertaining ways of reporting on the actions taken and the lessons learned. The aim is to highlight the creativity displayed and reinforce the feeling of competence.
Last but not least, Open Badges, a kind of forgery-proof digital certificate, can be used to trace and enhance the skills acquired during the internship. Accompanied by a precise description of the skills demonstrated, these badges can usefully enrich students' CVs and portfolios. This is one way of making the SESA a real springboard for future integration.
It would appear that the Health Service for Health Students is a promising opportunity to anchor the culture of therapeutic education in tomorrow's caregivers. By immersing them in preventive actions in contact with populations, it enables them to experiment with an educational posture and acquire skills in TVE.
However, the SESA will only bear fruit if it is invested as a genuine training lever, in close liaison with academic teaching. This implies ambitious pedagogical engineering work: strengthening student preparation, forging solid partnerships with internship sites, developing interprofessional skills, fine-tuning skills assessment...
In short, the aim is to make the SESA not just an interlude in the learning process, but a key link in a pedagogy of work-study that has yet to be invented. A pedagogy that constantly brings theoretical and experiential knowledge into dialogue, in a spirit of mutual enrichment.
This perspective calls for the collective mobilization of all those involved: institutional managers, trainers, internship supervisors, researchers... Everyone has a part to play in building an initial training program that fully integrates the challenges of therapeutic education. This is the only way to ensure that tomorrow's caregivers are equipped to meet the challenge of chronic disease.
The SESA offers a unique opportunity to move in this direction. By taking up the challenge of collaboration between the worlds of training, care and prevention, it is sketching out the contours of an educational approach firmly rooted in the realities of public health. It's an approach that needs to be developed and disseminated, to make therapeutic education a fully-fledged component of the health-care identity.
Illustration: Generated by AI - Flavien Albarras
References
1- Décret n° 2018-472 du 12 juin 2018 relatif au service sanitaire des étudiants en santé, 2018.
https:// www.legifrance.gouv.fr/jorf/id/JORFTEXT000037051024
2- CANADA, Public Health Agency of Canada, 2001. Social determinants of health and health inequalities. [online]. November 25, 2001. Available at: https: //www.canada.ca/fr/sante-publique/services/promotion-sante/sante-population/est-determine-sante.html [Accessed March 9, 2025].
3- Learning by Doing, [no date]. [online]. Available at: https: //www.beedeez.com/fr/blog/lapprentissage-par-laction-le-learning-by-doing [Accessed March 9, 2025].
4- Determinants sociaux de santé : mieux les comprendre pour mieux soigner, [no date]. Institut Montaigne [online]. Available at: https: //www.institutmontaigne.org/expressions/determinants-sociaux-de-sante-mieux-les-comprendre-pour-mieux-soigner [Accessed March 9, 2025].
5- CANADA, Public Health Agency of Canada, 2001. What is the population health approach? [online]. November 25, 2001. Available at: https: //www.canada.ca/fr/sante-publique/services/promotion-sante/sante-population/approche-axee-sur-la-sante-de-population.html [Accessed March 9, 2025].
6-HAS, Structuration d'un programme d'éducation thérapeutique du patient dans le champ des maladies chroniques, 2007.
https:// www.has-sante.fr/jcms/c_604958/etp-structuration-d-un-programme-d-education-therapeutique-du-patient-guide-methodologique
7- Article 84 - LOI n° 2009-879 du 21 juillet 2009 portant réforme de l'hôpital et relative aux patients, à la santé et aux territoires - Légifrance, [no date]. [online]. Available at: https: //www.legifrance.gouv.fr/jorf/article_jo/JORFARTI000020879791 [Accessed March 9, 2025].
8- Mise en œuvre du service sanitaire pour les étudiants en santé, Pr. Loïc Vaillant, 2018.
https:// sante.gouv.fr/IMG/pdf/rapport_service_sanitaire_pr_vaillant.pdf
9- Le Service Sanitaire en Région Centre-Val de Loire, 2020.
https://frapscentre.org/wp-content/uploads/2020/01/F2F5_SESA_2020_light.pdf
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