Paul Quesnay
email: paul.quesnay@gmail.com

Marianne Poumay

Rémi Gagnayre

Quesnay Paul

Gagnayre Rémi

patient education, and the competency-based approach? A cross-sectional survey

Keywords: Osteopathic medicine, Counseling, Patient education as topic, Education, Professional, Competency-based education, Surveys and Questionnaires

The literature review [START_REF] Levac | Scoping studies: advancing the methodology[END_REF][START_REF] Peters | Chapter 11: Scoping reviews[END_REF] aimed to describe the categories that were used when making questionnaire-based surveys to characterize the teaching, learning, and assessment methods in the health field and to complement the previous guidelines.

We selected articles based on the relevance of the themes as they related to our research question, rather than based on the studies' methodological specificities. The literature review was performed from January 2015 to March 2016; it was then updated through information monitoring. In this research, the categories were double-checked by two researchers from LEPS UR 3412. More details regarding this literature review and the questionnaire design is available in the Supplementary Materials.

For step 2, the categories were reviewed by the authors (researchers in health and education, including an osteopath). The categories found in the literature review referred to elements that are commonly accepted and/or present in French standards (related to teaching, learning, and evaluation methods).

In accordance with the recommendations (steps 5-7), a test phase of the questionnaire was performed by two researchers from the LEPS UR3412, followed by that with two osteopathic teachers (who were independent from the study) before a final rereading by two researchers from LEPS UR3412, and LabSET. As a result of these reviews, the questions were rephrased to make them more relevant and clearer. No questions were added.

Ethical approval (to be placed at the end of the article)

The present study was approved by the ethics committee of the Faculty of Psychology, Logopedics and Learning Sciences of the University of Liège on 21/11/2018 with the following reference: 1819-16.

INTRODUCTION

The rise and management of chronic diseases have become a major public health concern [START_REF]Life in the 21st century: A vision for all[END_REF] in the last few years. In 2010, World Health Organization (WHO) reported 36 million deaths per year from all chronic diseases combined [START_REF]Global status report on noncommunicable diseases 2010 Description of the global burden of NCDs, their risk factors and determinants[END_REF] . In France, one out of seven people have a chronic disease [START_REF] Bloch | Les maladies chroniques, Importance du problème : fréquence, contribution des différentes pathologies[END_REF] , such as diabetes, cardiovascular disease, cancer, or musculoskeletal pain, which is a main concern for osteopaths. Unfortunately, the chronic aspect of the disease deeply changes the organization of the health care system. To provide optimal continuity of patient care, there is a need for health professionals to develop appropriate care competencies to support patients' involvement in their own care.

As early as 1996, the Chronic Care Model [START_REF] Wagner | Organizing care for patients with chronic illness[END_REF] has highlighted the need for patients to engage in self-management in partnership with health professionals. Self-management allows patients to manage their lives in an optimal way according to their own health needs, the specifics of their illness, and their life context [START_REF]Health literacy, The solid facts[END_REF] . Studies have shown the efficacy of self-management through patient education interventions for numerous chronic illness [START_REF] Lagger | Efficacy of therapeutic patient education in chronic diseases and obesity[END_REF] , including musculoskeletal disorders [START_REF] Randhawa | The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration[END_REF][START_REF] Zahari | The effectiveness of patient education in improving pain, disability and quality of life among older people with low back pain: A systematic review[END_REF] . For healthcare workers, patient education aims to teach patients self-care and disease management [START_REF]Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases : report of a WHO working group[END_REF] .

In osteopathic medicine, international recommendations and registration guidelines [START_REF] Fore | European framework for Standards of osteopathic practice[END_REF][11][START_REF]Osteopathy code of conduct[END_REF][START_REF] Gosc | Osteopathic Practice Standards[END_REF] have encouraged osteopaths to engage patients in self-management through patient education [START_REF] Sciomachen | Core competencies in osteopathy: Italian register of osteopaths proposal[END_REF] . However, this practice continues to be a challenge in the clinical setting [START_REF] Leach | Patients' expectations of private osteopathic care in the UK: a national survey of patients[END_REF] . A previous study showed that, during consultations, French osteopaths were more likely to provide information and counseling rather than support the patient's learning required to develop self-management skills [START_REF] Quesnay | Survey on counseling practice at French osteopathic practitioners: toward therapeutic education practice?[END_REF] . Osteopaths were found to face difficulties in adapting their advice and practicing patient education when the patient needed to commit to a behavioral change, such as changing their life or work habits to maintain his health situation [START_REF] Quesnay | Survey on counseling practice at French osteopathic practitioners: toward therapeutic education practice?[END_REF] . An important part of the difficulties in implementing patient education could be related to a lack of training [START_REF] Thomson | A qualitative grounded theory study of the conceptions of clinical practice in osteopathy -A continuum from technical rationality to professional artistry[END_REF] . This finding is consistent with the conclusions of previous studies that emphasized the need to train healthcare professionals in patient education [START_REF]Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases : report of a WHO working group[END_REF][START_REF] Leach | Patients' expectations of private osteopathic care in the UK: a national survey of patients[END_REF][START_REF] Quesnay | Survey on counseling practice at French osteopathic practitioners: toward therapeutic education practice?[END_REF][START_REF] Zamani | Analysis of exercise content in undergraduate osteopathic education -A content analysis of UK curricula[END_REF][START_REF] Zamani | Exploring the use of exercise therapy in UK osteopathic practice[END_REF] . Indeed, patient education requires special training [START_REF] Forbes | Effectiveness of patient education training on health professional student performance: A systematic review[END_REF] that is different from communication or counseling [START_REF] Fournier | Doctor-Patient Communication and Patient Education, Notions to Be Reconciled: Intersecting Contributions of Literature[END_REF] . For this reason, the Italian Register of Osteopaths has proposed that patient education be integrated into the core competencies of osteopaths [START_REF] Sciomachen | Core competencies in osteopathy: Italian register of osteopaths proposal[END_REF] . In France, osteopathic training has recently been the subject of legislation, [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] defining new standards for education and practice. In terms of education, these new standards require the implementation of a competency-based approach, [START_REF] Nguyen | Approche par objectifs ou approche par compétences ? Repères conceptuels et implications pour les activités d'enseignement, d'apprentissage et d'évaluation au cours de la formation clinique[END_REF][START_REF] Fernandez | Varying conceptions of competence: an analysis of how health sciences educators define competence[END_REF][START_REF] Gruppen | Competency-based education: programme design and challenges to implementation[END_REF] similar to other osteopathic frameworks [START_REF] Riley | Innovation in graduate medical education -using a competency based medical education curriculum[END_REF] . In terms of practice, the new French osteopathic standards [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] include patient education, which is grouped with counseling, the care relationship, and communication under the umbrella term "relational competency" (competency 4), which is defined as "conducting a relationship in the context of an osteopathic intervention." Nevertheless, the grouping of these different themes within a single competency can lead to confusion and a lack of precision about what relational competency actually covers. For example, counseling is described through its content as follows: "Recommendations to the person: gestural activity, posture, lifestyle, care by another professional…" [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] It is not described in terms of activities that are specific to patient education [START_REF]Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases : report of a WHO working group[END_REF][START_REF] Marchand | La formation des soignants à l'éducation thérapeutique | Association Développement et Santé[END_REF] , such as assessing the patient's understanding and knowledge and helping the patient adopt new behaviors in the context of their life.

To our knowledge, no other studies have focused on the teaching, learning, and assessment methods related to relational competency in initial osteopathic training programs or examined the role of the key topics of patient education in relational competency. Some topics that may belong to the relational competency have been addressed separately in osteopathy, such as advice regarding exercise content [START_REF] Zamani | Analysis of exercise content in undergraduate osteopathic education -A content analysis of UK curricula[END_REF] , communication teaching [START_REF] Muddle | Learning and teaching of patient-centred communication skills in allied healthcare manual therapy students: A systematic review[END_REF] or assessment methods [START_REF] Vaughan | Methods of assessment used by osteopathic educational institutions[END_REF] . In health literature, teaching relational competency encompasses studies on the care relationship [START_REF] Even | Enseigner la relation médecin-malade : Présentation d'une expérience pédagogique développée à la faculté de médecine de Créteil[END_REF] , communication [START_REF] Losh | Teaching inpatient communication skills to medical students: an innovative strategy[END_REF][START_REF] Lewis | Description and evaluation of an education and communication skills training course in HIV and AIDS for dental consultants[END_REF][START_REF] Evans | Designing patient-focused information: an opportunity for communicating anatomically related information[END_REF][START_REF] Millette | L'apprentissage de la communication par les médecins: aspects conceptuels et méthodologiques d'une mission académique prioritaire[END_REF][START_REF] Boulé | Stratégies d'animation de groupe sur la communication patent-médecin-famille[END_REF][START_REF] Ibrahim | Étude préliminaire des effets à court et long terme d'un dispositif de formation à la communication d'une mauvaise nouvelle[END_REF] , counseling [START_REF] Chang | A clinical nutrition course to improve pharmacy students' skills and confidence in counseling patients[END_REF][START_REF] Kripalani | Development and evaluation of a medication counseling workshop for physicians: can we improve on "take two pills and call me in the morning[END_REF] , therapeutic patient education (TPE) [START_REF] Forbes | Effectiveness of patient education training on health professional student performance: A systematic review[END_REF][START_REF] Van Rooij | Enquête sur l'enseignement de l'éducation thérapeutique auprès de 30 instituts de formation en soins infirmiers de la région Île-de-France[END_REF] , and health literacy [START_REF] Margat | Health Literacy » et éducation thérapeutique du patient : Quels rapports conceptuel et méthodologique?[END_REF][START_REF] Margat | Interventions en littératie en santé et éducation thérapeutique : une revue de la littérature[END_REF] . In France, initial training on patient education in other health professions is either poorly documented or indicates highly variable methods. It emphasizes the need to document training on patient education [START_REF] Van Rooij | Enquête sur l'enseignement de l'éducation thérapeutique auprès de 30 instituts de formation en soins infirmiers de la région Île-de-France[END_REF][START_REF] Justumus | L'enseignement de l'éducation thérapeutique du patient dans les Instituts de Formation en Soins Infirmiers Français[END_REF] .

The aim of this study was to determine the teaching, learning, and assessment methods related to relational competency in French initial training programs. The characterization of these methods will allow us to specify the scope of relational competency and its relevance for the educators in these training programs. We will focus more closely on the role of patient education within relational competency. The methods will be examined in the light of the competency-based approach prescribed by the new French osteopathic standards for education and practice.

MATERIALS AND METHODS

Initial osteopathic training in France

In France, the new standards [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] for education and practice determine the minimum content of education and serve as the basis for the accreditation and approval of schools. Initial osteopathic training lasts for approximately 5 years. The first 3 years mostly include classroom teaching and some clinical teaching, at an 80-20 split. This ratio is reversed for the last 2 years of training. There are a total of six competencies with 57 associated teaching units (TUs). However, the link between competencies and TUs is not always explicit in the standards, and 18 intended learning outcomes (ILOs) (from the six competencies) are not directly linked to TUs.

A questionnaire-based survey

A questionnaire was designed based on the following 7-step process recommended by the Association for Medical Education in Europe 43 : 1. conduct a literature review; 2. conduct interviews and/or focus groups; 3. synthesize the literature review and interviews/focus groups; 4. develop items; 5. collect feedback on the items through expert validation; 6. employ cognitive interviews to ensure that respondents understand the items as intended; and 7. conduct pilot testing.

The literature review [START_REF] Levac | Scoping studies: advancing the methodology[END_REF][START_REF] Peters | Chapter 11: Scoping reviews[END_REF] aimed to describe the categories that were used when making questionnaire-based surveys to characterize the teaching, learning, and assessment methods in the health field and to complement the previous guidelines.

We selected articles based on the relevance of the themes as they related to our research question, rather than based on the studies' methodological specificities. The literature review was performed from January 2015 to March 2016; it was then updated through information monitoring. In this research, the categories were double-checked by two researchers [laboratory details excluded from blinded version of the manuscript]. More details regarding this literature review and the questionnaire design is available in the Supplementary Materials.

For step 2, the categories were reviewed by the authors (researchers in health and education, including an osteopath). The categories found in the literature review referred to elements that are commonly accepted and/or present in French standards (related to teaching, learning, and evaluation methods).

In accordance with the recommendations (steps 5-7), a test phase of the questionnaire was performed by two researchers from the [laboratory details excluded], followed by that with two osteopathic teachers (who were independent from the study) before a final rereading by two researchers from [laboratory details excluded] and [laboratory details excluded]. As a result of these reviews, the questions were rephrased to make them more relevant and clearer. No questions were added.

Questionnaire design

We developed 20 questions based on categories from the literature review (see Supplementary Materials for further details). The categories were as follows: characteristics of the respondent, characteristics of teaching, characteristics of the assessment, and perspectives of curricular evolution.

Regarding the characteristics of teaching, the subcategories as follows: type of teaching (courses and clinical learning), general characteristics (year, duration, format, course title, or TU), teaching strategy (including target competencies and ILOs), and teaching methods and techniques. Regarding the characteristics of assessment, the subcategories as follows: general characteristics (year and format) and the assessment strategy (competency and ILOs used for assessment, evaluation methods, and techniques).

The ILOs in QII.3 (See Supplementary Materials) were derived from the description of relational competency in the French osteopathic standards for education and practice [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] . Three ILOs were added from patient education literature [START_REF]Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases : report of a WHO working group[END_REF] ("using patient education tools and materials," "helping the person to transfer the advice given into their daily life," and "monitoring patient education and advice over time").

To facilitate the analysis of responses, majority of the questions were closed; questions were either single-choice or multiple-choice or used a Likert-type scale. Odd (3 point) Likert scale was used for QIII.1: opinion on the importance of relational competence in relation to other competences. Even (4 points) Likert scale was used for QIII.2: obstacles preventing the development of relational competence. The only open sections were in QI.3 (regarding the names of TUs, the number of hours, and the main assessment and teaching methods) and the respondent's comment section.

Study population and survey progress

The population for the survey included 28 initial training institutes in osteopathy certified by the French state (decree pertaining to osteopathy training-2014) 46 . Each institute was expected to generate one answer. The survey was administered from January to October 2019. The institutes received three email reminders and two follow-up telephone calls regarding this study.

Data collection and analysis

The online tool LimeSurvey® (Hamburg, Germany) was used to encode and administer the questionnaire. The data collected from the questionnaire were anonymous; respondents were not asked about their identity, and it was not possible to identify them. The ethical provisions appeared on the header of the questionnaire.

For descriptive analysis of the data (Microsoft Excel®, Redmond, Washington, U.S.), we presented the measures of frequency (number, sum, and ratio when needed), measures of central tendency (mean) and measures of dispersion (standard deviation).

RESULTS

Profile of respondents

The online questionnaire was completed by eight out of 28 institutes, with a response rate of 28.5%. However, despite two email follow-ups and one telephone follow-up, 19 institutes failed to respond. One institute refused to participate. Keeping in line with the anonymous nature of the survey, the characteristics of the institutes were not examined. The respondents (Table 1) worked either as education coordinators (n = 6/8) or held leadership positions (n = 2/8).

Intended learning outcomes and teaching methods related to relational competency

As shown in Table 1, majority of the proposed ILOs, whether from the standards or the patient education literature, were considered as "contributing to relational competency." At least five out of seven institutes chose these ILOs, except for "monitoring patient education and advice over time" (n = 4/7). Nevertheless, the institutes used them for courses or clinical learning to a variable extent.

For teaching, all the institutes selected the following ILOs (n = 7/7): "welcoming the person and his or her family," "identifying the person's specific needs and his/her life context," and "mastering verbal and nonverbal communication techniques." The respondents tended to give less importance to the ILOs from patient education, such as "monitoring patient education and advice over time" (n = 2/7) and "using patient education tools and materials" (n = 2/7).

Courses took place during academic years 2-5 in varying proportions across the eight institutes (Table 1). The format and techniques used in these courses did not vary based on the academic year; a lecture format was predominantly used, followed by clinical case studies and role playing.

In seven out of eight respondents, the development of relational competency was supported by clinical learning. Only one ILO was selected by all the institutes (n = 7/7): "providing relevant information and checking patient's understanding."

The respondents tended to give less importance to the ILOs from patient education, such as "monitoring patient education and advice over time" (n = 3/7) and "using patient education tools and materials" (n = 2/7). During years 1 and 2, they were based on the observations of senior students. In year 3, they were based on observation and semidirected consultations defined as "progressive learning and performing certain activities with patients during consultations in the presence of an osteopath teacher." In years 4 and 5, in addition to semidirected consultations, clinical learning was also conducted based on self-directed consultations defined as "consultations entirely conducted by a student under supervision."

Volume and content of teaching

The volume of teaching (hours) linked to relational competency varied from years 2 to 5 (Table 2), ranging from 21 ± 4.1 annual hours in year 2 to 158.3 ± 58.1 annual hours in year 5. This variation depended on Tus, which each institute declared to be tied to the competency. This was higher in years 4 and 5 since three respondents included "clinical training" in the number of hours. The volume of teaching had the same percentage when it was brought back to the overall prescribed volume of teaching per year.

The courses were mainly attached to the following TUs: psychology, healthcare, relationships and communication, sociology, and nutrition. Aside from year 3, the institutes generally associated relational competency with only one TU per year.

Assessment

Less than three out of seven institutes reported that they did not assess the ILOs as previously described (Table 3). No respondents assessed the following ILOs, including "identifying the person's level of understanding" and those from patient education "using patient education tools and materials" and "monitoring patient education and advice over time." The reported evaluation techniques did not vary among the years. Written assessments were predominant, with techniques such as multiple-choice questions and written questions.

For the clinical evaluation of relational competency, the ILOs previously described were assessed (for at least five out of seven institutes). The ILOs regarding patient education were less frequently evaluated, specifically "using patient education tools and materials" (n = 1/7) and "monitoring patient education and advice over time" (n = 3/7). Evaluations often took place during self-directed consultations (n = 7/7) and semidirected consultations (n = 6/7). Grids (common to all competencies) were largely used as an evaluation tool (n = 7/7). To a lesser extent, observational reports (n = 3/7) and clinical portfolios were also used (n = 3/7). No respondent used grids dedicated to the relational competency.

Table 3: Assessment characteristics of relational competency in French osteopathic training (n = 8)

Importance of teaching relational competency and intended pedagogical change

For most of the institutes (n = 7/8), relational competency is considered just as important as teaching other competencies (Table 4). In fact, seven out of eight institutes cited the lack of trained teachers as the main obstacle to the development of relational competency in courses, declaring this either "very important" or "important." Thus, teacher training was reported as being the main lever for developing relational competency (n = 7/8). Multidisciplinary work and the development of new teaching tools were also cited (n = 2/8) albeit to a lesser extent. Nevertheless, the institutes also reported a lack of available hours in the overall program that prevented the development of teaching, with three out of eight respondents declaring this as being "very important" or "important." Half of the institutes did not plan on changing their teaching methods, whereas a quarter considered developing practical or clinical instructions.

DISCUSSION

The aim of this study was to determine the teaching, learning, and assessment methods related to relational competency in French initial training programs (competency 4) and identify the role of patient education within this relational competency. The results have been discussed in relation to the competency-based approach prescribed by the new French osteopathic standards for education and practice.

An undervalued education

Seven respondents (88%) considered relational competency as being just as important as other clinical competencies. This is in line with the recommendations made to add this relational competency to the core competencies and highlights its importance when practicing osteopathy and during training [START_REF] Fragstein | UK consensus statement on the content of communication curricula in undergraduate medical education[END_REF] . However, as in any survey, social desirability bias [START_REF] Butori | Les biais de réponse -Impact du mode de collecte des données et de l'attractivité de l'enquêteur[END_REF] cannot be ruled out as an explanation for this result.

Respondents reported the presence of relational competency in many courses. In addition, throughout their training, students are exposed to clinical learning (and thus to the practice of relational competency) by observing and learning how to conduct a consultation. Regardless, teaching relational competency accounts for a total of 7% of teaching time each year, indicating that pedagogical support for relational competency seems to be undervalued. It is difficult to compare this result with other recent data due to the lack of published evidence in literature on manual therapy [START_REF] Muddle | Learning and teaching of patient-centred communication skills in allied healthcare manual therapy students: A systematic review[END_REF] . Nevertheless, this small amount of time dedicated to relational competency may suggest that the courses are centered on the biomedical aspects of care [START_REF] Hulsman | Teaching clinically experienced physicians communication skills. A review of evaluation studies[END_REF] . It is close to the instructions reported in the 2000s in other health professions [START_REF] Hulsman | Teaching clinically experienced physicians communication skills. A review of evaluation studies[END_REF] .

Lack of alignment between intended learning outcomes and content

The courses declared by the majority of the respondents (more than five out of eight depending on the EU) were strictly in line with the TUs prescribed by the French osteopathic standards for education and practice [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] , but these TUs (i.e., psychology, sociology, and nutrition) are not specific to relational competency.

In France, the new standards for education and practice define the minimum content of teaching and serve as the basis for the accreditation of schools. Our results may suggest that these institutes have fully applied these standards, but there may be a social desirability bias [START_REF] Butori | Les biais de réponse -Impact du mode de collecte des données et de l'attractivité de l'enquêteur[END_REF] , indicating that the declared practices are inaccurate [START_REF] Jouquan | De l'approche par objectifs à l'approche par compétences. Faut-il jeter le bébé avec l'eau du bain ?[END_REF] . Conversely, it is interesting to note that some respondents (1-3 depending on the TUs) did not mention these TUs, suggesting they did not find the TUs to be tied to relational competency, did not know they existed, or did not practice them in their institutes.

The TUs and their content do not seem to be consistent with the ILOs used for classroom and clinical instruction (Tables 1 and3). Based on these ILOs, there seems to be a disparity between what is taught and what is assessed. For instance, all institutes (n = 7) viewed the ILO "formulating clear and argued educational objectives for the patient" as part of relational competency. Five institutes used it for teaching, whereas six used it for clinical learning. One institute declared to assess it in the context of its teaching program and five institutes did the same during clinical learning.

Regarding this type of educational misalignment [START_REF] Cegala | Physician communication skills training: a review of theoretical backgrounds, objectives and skills[END_REF] , it has been indicated that it is hard to determine what is really taught and assessed, as well as how students are truly trained in relational competency. Further studies including interviews and direct observation are needed to describe this more extensively.

Teaching techniques oriented toward the transmission of theoretical knowledge

The predominant teaching format is the lecture format, taking place in large groups. This format, as we know, largely promotes theoretical knowledge transmission. In 2013, Lalonde [START_REF] Lalonde | Problem-based learning in osteopathic education[END_REF] showed that this format was predominant in osteopathic schools in Europe and Canada and pleaded for the inclusion of new teaching methods such as Problem Based Learning. Thus, the French standards recommend that half of the teaching time dedicated to relational competency [START_REF] Légifrance | Arrêté du 12 décembre 2014 relatif à la formation en ostéopathie[END_REF] take place in small groups.

Large group teaching does not seem appropriate and may even be contradictory to the techniques mentioned by the institutes, specifically case studies and role playing. These techniques are relevant to develop relational competency [START_REF] Rider | Communication skills competencies: definitions and a teaching toolbox[END_REF] . It would allow students to develop higher taxonomic levels of mental processes and contextualize osteopathic learning [START_REF] Fitzgerald | Simulated learning activities as part replacement of clinical placements in osteopathy: A case study[END_REF] .

In addition, clinical learning complements classroom learning and allows students to be confronted with authentic learning situations [START_REF] Hamdy | Authentic learning in health professions education: problem-based learning, team-based learning, task-based learning, case-based learning and the blend[END_REF] in the early years of their training. Despite such a contribution, however, a medical literature [START_REF] Cegala | Physician communication skills training: a review of theoretical backgrounds, objectives and skills[END_REF] has indicated that it is impossible to determine how clinical learning specifically prepares students for relational competency, considering the previously mentioned misalignment among relational competency, ILOs, and assessment.

Assessment partially aligned with competencies

The institutes reported multiple-choice questions and essay questions as the main assessment formats in years 2 and 3. Although these modalities are appropriate for assessing theoretical knowledge, they cannot assess the complexity of relational competency. Medical literature [START_REF] Laidlaw | Communication skills: an essential component of medical curricula. Part I: Assessment of clinical communication: AMEE Guide No[END_REF] and osteopathic research [START_REF] Fitzgerald | Simulated learning activities as part replacement of clinical placements in osteopathy: A case study[END_REF][START_REF] Vaughan | The OSCE in a pre-registration osteopathy program: Introduction and psychometric properties[END_REF][START_REF] Vaughan | The mini Clinical Evaluation Exercise (mini-CEX) in a preregistration osteopathy program: Exploring aspects of its validity[END_REF] have suggested the use of more relevant methods such as the objective structured clinical examination and the mini-clinical evaluation exercise, as well as the more contextualized situations of standardized patients and simulations. For years 4 and 5, this observation should be balanced with other findings. Despite the predominance of written assessment methods, more institutes highlighted assessment methods linked to clinical learning or to practical exams such as the objective structured clinical examinations.

Depending on their design, the evaluation tools used for clinical learning (criterion-based grids common to all competencies) can be consistent for assessing relational competency [START_REF] Humphrey-Murto | Assessment pearls for competency-based medical education[END_REF] . Additional research is required to analyze the content and the docimological qualities of these tools, as recommended by the literature [START_REF] Fletcher | Clinical competence examination -Improvement of validity and reliability[END_REF] . The use of portfolios does support the development of student reflective practice [START_REF] Buckley | The educational effects of portfolios on undergraduate student learning: A Best Evidence Medical Education (BEME) systematic review[END_REF] . This formative assessment technique is promoted in osteopathic literature [START_REF] Vaughan | Introducing a portfolio assessment in a preprofessional osteopathy program[END_REF] , but it remains underdeveloped, being adopted in only three institutes.

Whether for clinical or in-course assessment, our findings indicate a poor development of assessment tools. This is in line with the findings of Vaughan et al. in 2012 regarding assessment methods in osteopathic institutes in other countries [START_REF] Vaughan | Methods of assessment used by osteopathic educational institutions[END_REF] .

Relational competency that includes a patient education approach

Based on the ILOs tied to relational competency as reported by the institutes, it can be argued that the institutes view patient education practices as a professional activity that is a part of relational competency. This is consistent with the observations made in a previous study [START_REF] Quesnay | Survey on counseling practice at French osteopathic practitioners: toward therapeutic education practice?[END_REF] .

However, ILOs related to patient education do not seem to be frequently used for teaching or clinical learning. This could be explained by the lack of clarification of the French standards toward patient education. As suggested in a recent proposition made by the Italian Register of Osteopaths, French osteopathic standards for education and practice could distinguish competencies related to osteopathic care, health promotion and prevention, and therapeutic education [START_REF] Sciomachen | Core competencies in osteopathy: Italian register of osteopaths proposal[END_REF] . This proposition highlights the importance of reviewing the French standards to support the development of patient education in osteopathy and courses dedicated to it 20 .

Another explanation seems to be the lack of trained educators in relational competency or patient education. The institutes considered training as a possible lever and perspective for improvement. Other studies have also highlighted the concern of osteopathic schools regarding the improvement of pedagogical training of educators, for instance, in relation to the evaluation of clinical competency [START_REF] Vaughan | Methods of assessment used by osteopathic educational institutions[END_REF] . Despite the improvements that still need to be made in osteopath training, our results could be viewed as a reflection of the current evolution of the osteopaths' care and models toward a person-centered approach [START_REF] Esteves | Models and theoretical frameworks for osteopathic care -A critical view and call for updates and research[END_REF] .

Competency-based approach as an emerging practice

Several findings of our study are consistent with literature on the competency-based approach [START_REF] Nguyen | Approche par objectifs ou approche par compétences ? Repères conceptuels et implications pour les activités d'enseignement, d'apprentissage et d'évaluation au cours de la formation clinique[END_REF][START_REF] Fernandez | Varying conceptions of competence: an analysis of how health sciences educators define competence[END_REF][START_REF] Gruppen | Competency-based education: programme design and challenges to implementation[END_REF] . This is the case for the teaching techniques reinforced by clinical learning situations that contextualize learning (i.e., case studies and role play) [START_REF] Tardif | L'évaluation des compétences. Documenter le parcours de développement[END_REF] . We also noted the relevance of several assessment tools for evaluating competencies such as observation reports and the clinical portfolio. These tools are well suited to document the development of students' competencies throughout their training years [START_REF] Vaughan | Introducing a portfolio assessment in a preprofessional osteopathy program[END_REF] .

Nevertheless, the competency-based approach is still an emerging practice in many institutes [START_REF] Gervais | The operational definition of competency-based education[END_REF] . The distribution of teaching indicates that the programs of these institutes are organized on the basis of sequential learning models, with the early years focusing on theory and knowledge acquisition [START_REF] Vaughan | Methods of assessment used by osteopathic educational institutions[END_REF] . Thus, TUs, as well as teaching and evaluation techniques, show a predominance of knowledge transmission. This planning model diverges from the competency-based approach [START_REF] Gruppen | Competency-based education: programme design and challenges to implementation[END_REF] and is not appropriate in osteopathy [START_REF] Vaughan | Methods of assessment used by osteopathic educational institutions[END_REF] . This causes a discrepancy between competency-based learning outcomes and knowledge instruction and assessments. This discrepancy leads us to suggest that the resulting educational practices cannot support student competency development [START_REF] Tardif | Pre-service Teacher Training Programs : Outcomes of recent reforms and new trends towards effective professional training[END_REF] .

Our results highlight the difficulties that institutes have in implementing relational competency and in embedding their programs into a comprehensive competency-based approach [START_REF] Gervais | The operational definition of competency-based education[END_REF] . This difficulty can be explained-according to our hypothesis-by the educational reform driven by the new French osteopathic standards for education and practice, which have been described as ambiguous and unclear [START_REF] Hébrard | approche par les compétences » et quels référentiels pour la formation professionnelle aux métiers de la relation humaine ? Les dossiers des sciences de l'éducation[END_REF] . These standards contain some elements that prevent the competency-based approach from being fully implemented and make it more confusing. For instance, a large amount of competencies are listed [START_REF] Poumay | Organiser la formation à partir des compétences -Un pari gagnant pour l'apprentissage dans le supérieur[END_REF] , but competency is segmented and described in terms of TUs and content, as in Flexner's models of education [START_REF] Fernandez | Varying conceptions of competence: an analysis of how health sciences educators define competence[END_REF] . Furthermore, the standards do not detail the milestones that reflect progression in competencies [START_REF] Gruppen | Competency-based education: programme design and challenges to implementation[END_REF] .

Only one out of the eight institutes in this study viewed the latest French standards of practices as an opportunity for change. It is important to consider that transitioning to a competency-based approach represents a true paradigm shift [START_REF] Camacho | Shifting gears in the classroom-movement toward personalized learning and competency-based education[END_REF] and requires renewed educational practices [START_REF] Nguyen | Approche par objectifs ou approche par compétences ? Repères conceptuels et implications pour les activités d'enseignement, d'apprentissage et d'évaluation au cours de la formation clinique[END_REF] . Unfortunately, without proper support and guidance, institutes may view competency-based approach as a constraint rather than an opportunity for change [START_REF] Poumay | Organiser la formation à partir des compétences -Un pari gagnant pour l'apprentissage dans le supérieur[END_REF] .

Limitations of the study

The results of this survey should be weighed against the response rate of 28.5% (eight responses from the 28 institutes that were contacted). A larger sample is needed for more representative results. Nevertheless, this leads us to wonder whether our target population is interested in documenting its own practices, since the present study is primarily descriptive. The length and methodical nature of the questionnaire, which reviewed the institutes' entire curricula, could not be avoided. This may have discouraged respondents. Moving forward, it would be advisable to use mixed designs that would also be based on qualitative methods, as is the case in other studies [START_REF] Vaughan | Methods of assessment used by osteopathic educational institutions[END_REF] . This could help avoid the risk of formatted responses due to the nature of the survey [START_REF] Saint-André | Avantages et limites des approches méthodologiques utilisées pour étudier les pratiques enseignantes[END_REF] , as well as refine our understanding of teaching practices aimed at developing relational competency and the competency-based approach in institutes.

CONCLUSION

The results of the study highlight the difficulty of French osteopathic institutes in implementing relational competency. Although there is dedicated teaching and clinical learning, the volume of teaching is still undervalued, and there appears to be a misalignment among ILOs, teaching methods, and evaluation methods. To explain these results, further research is needed on how French standards are understood, how they are assimilated by educators, and how they are translated into educational practice. In addition, the adequacy of educator training for effective implementation of the competency-based approach should be questioned. Solving these issues constitutes a real educational challenge that osteopathic institutes could take up.

Ethical approval [Ethics committee approval was excluded from the blinded manuscript as recommended by the editor]

Table 1 :

 1 Intended learning outcomes and teaching methods for relational competency in French osteopathic training (n = 8)

Table 2 :

 2 Volume and content of teaching in French osteopathic training (n = 8)

Table 4 :

 4 Importance of teaching relational competency and intended pedagogical change in French osteopathic training (n = 8)

Table 1 :

 1 Intended learning outcomes and teaching methods for relational competency in French osteopathic training (n=8)

	Instruction's	Courses		Yes				8/8
	modality	Clinical learning		Yes				7/8
				No, not yet			1/8
	Intended learning outcomes n=7				Contributing to the relational competency	Used in teaching program	Used in clinical learning
		Welcoming the person and his or her family	7/7		7/7	6/7
		Identifying the person's level of			7/7		5/7	6/7
		understanding
		Identifying the person's specific needs and	6/7		7/7	6/7
		his/her life context
		Mastering verbal and non-verbal			7/7		7/7	5/7
		communication techniques
		Mastering listening techniques			7/7		6/7	5/7
		Providing relevant information and checking	7/7		5/7	7/7
		the patient's understanding
		Formulating clear and argued educational	7/7		5/7	6/7
		objectives for the patient
		Using patient education tools and materials	5/7		2/7	2/7
		Helping the person to transfer the advice	6/7		4/7	5/7
		given into their daily life
		Monitoring patient education and advice over	4/7		2/7	3/7
		time
		Year 1	Year 2	Year 3	Year 4	Year 5	Sum
	Number of institutes declaring courses linked to the relational competency	0	6	8	7	6
	Format	Lecture format		4	3	5	4	16/46
	(open questions)	Tutorials		1	3	1	0	5/46
		Clinical learning		0	0	0	2	2/46
	Teaching Methods	Clinical case		3	5	3	1	12/46
	(open questions)	Roleplay / simulation		1	6	0	0	7/46
		Observational report		0	1	0	1	2/46
		Flipped Classroom		0	1	0	1	2/46
	Clinical learning	Observation	2	4	5	3	1
	activities (n=7)	Semi-directed consultation	0	0	5	7	4
		Self-directed consultation	0	0	0	3	7
		Observation does not support relational competency			2/7

Table 2 :

 2 Volume and content of teaching in French osteopathic training (n=8)

	Year 1	Year 2	Year 3	Year 4	Year 5

Table 3 :

 3 Assessment characteristics of relational competency in French osteopathic training (n=8)

	Intended
	learning
	outcomes
	assessed
	n=7/8