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CIN: Computers, Informatics, Nursing:
doi: 10.1097/CIN.0000000000000014
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The Patient Perception of the Nurse-Patient Relationship When Nurses Utilize an Electronic Health Record Within a Hospital Setting


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Author Information

Author Affiliation: Edgewood College, Madison, WI.

This work is part of a doctoral thesis completed through Case Western Reserve University in Cleveland, OH.

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Beth Strauss, RN, DNP, ACNS, BC, 429 South Burr Oak Ave, Oregon, WI ( bstrauss@edgewood,edu).

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Research has focused on electronic health record use during patient interactions primarily from a physician or advanced practice nurse perspective. Few if any empirical data exclusively explored the patient’s hospital experience of the nurse-patient relationship when nurses use an electronic health record to communicate with them during patient interactions. The study was conducted to determine how use of a computer for documentation and care delivery influences communication dynamics between a nurse and patient within an inpatient setting. Hermeneutic phenomenology was the methodology used. A purposeful sample of 11 adults from a medical unit of a community hospital comprised the sample. After institutional review board approval was obtained, a questionnaire, addressing demographic data and information about previous computer and electronic health record use, was administered. In-depth interviews were conducted to uncover patient’s experiences and reactions to their interactions with nurses as electronic health records were being utilized. Four themes were derived from the data analysis: (1) presence, (2) respect, (3) knowledge, and (4) trust and safety. Recommendations, including logistical modifications and innovative educational approaches, were derived from the themes and related findings.

Nursing, whose status has always been affected by humanity and world progress, has been called the oldest of arts and the youngest of professions.1 While nurses believe that they are connecting to a patient in a caring and helping manner, the patient experience as a recipient of nursing care is the ultimate measure of successful nursing practice.2 The introduction of electronic health record utilization, in particular, has altered traditional communication dynamics between nurses and patients. Communication between a nurse and patient now transpires within the presence of a portable computer system containing an electronic health record.

The knowledge generated from this inquiry provides nurses with further understanding of the nurse-patient relationship, as experienced by the patient within the technological healthcare environment. In addition, this study adds to the nurse-patient relationship and electronic health record literature. Specifically, an understanding of the patient experience when nurses use electronic health records to communicate during inpatient interactions will be gained. Lastly, this research provides nurses with valuable information to provide effectual patient-centered care and successful nurse-patient communication within the technological environment.

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Successful communication between a nurse and patient is required for effective nursing care.3,4 Traditionally, healthcare records were in a pen-and-paper format that required handwriting clinical data into a health record located outside the patient’s room or at a central nursing station. Electronic health records combine multiple pen-and-paper documents into one easily accessible electronic patient database that can be brought promptly to the patient. Dual communication and development of a nurse-patient relationship now transpire as computers, containing an electronic health record, are used within the healthcare environment. It was unclear how use of a computer for documentation and care delivery influences communication dynamics between a nurse and patient within an inpatient setting.

The purpose of this phenomenological research study was to explore how patients perceive their relationship with nurses when electronic health records are used to communicate during patient interactions. For patients admitted to the hospital with a chronic illness, the research question is simply: What is the experience of hospitalized patients when nurses communicate with them while using an electronic health record? Constructs of Hildegard Peplau’s5 Interpersonal Relations in Nursing Theory and attributes of effective communication within a nurse-patient relationship provide a conceptual frame of reference for the study.

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Although electronic health records have been demonstrated to reduce medical errors, little is known about how this form of documentation affects patient-nurse communication.6 The purpose of a literature review is to undertake a systematic and comprehensive review of the literature to identify current knowledge about a phenomenon.7 The phenomenon explored was the patient’s perceptions of the nurse-patient relationship as nurses utilize an electronic health record within a hospital setting. Key terms searched in this literature review include (1) nurse-patient relationships, (2) communication, (3) patient experience, (4) electronic health record, and (5) computer utilization.

Nurse-patient relationships have been explored over the course of 60 years in order to elucidate dynamics of the nurse-patient relationship. The majority of empirical studies on nurse-patient relationships occurred in the 1980s and late 1990s.8–14 The ability of a nurse to effectively communicate and provide a caring nurse presence can result in positive patient outcomes such as trust, partnership, caring, and a perceived helping relationship.8,15,16 Ineffective nurse-patient communication can result in negative consequences such as distancing, avoidance, meaninglessness, anomie, and miscalculation of a patient’s healthcare concern, issue, or question.2,8,16,17 In the studies reviewed, effective nurse-patient relationships occurred when a patient developed feelings of trust and an approachable caring relationship with the nurse.16–18 Ineffective nurse-patient relationships occur when a patient perceived distancing of the nurse by shifting focus from patient caring to object management.19

Electronic health records provide a transition from multiple paper sources to an easily accessible electronic patient database. Fingertip accessibility of clinical data in an electronic health record format results in fewer healthcare provider errors and a more timely provision of healthcare services.6,20 In an electronic health record format, healthcare providers have quick access to an updated medical and surgical history, medication list, allergy information, diagnostics tests ordered, and other care provider information.6,20

In a computerized electronic health record environment, complexity of a patient’s health history resulted in a shift of focus, by the healthcare provider, from patient engagement to object management of electronic health record data.21,22 Healthcare provider expertise and comfort level with using an electronic health record also influenced the patient provider relationship as technology skills were associated with provider competency.22–26 A patient’s personal communication with a healthcare provider corresponded to an effective provider-patient relationship, whereas an ineffective relationship resulted in a patient finding healthcare information on his/her own.27 A nurse may find conflict between caring for the patient and operational activities within the electronic health record environment, resulting in provider frustration and perceived decreased consumer satisfaction.25,26,28

The above literature review suggests that provider and patient interaction within a computerized healthcare environment is affected by several concepts: (1) computer and patient orientation, (2) complexity of the healthcare concern, and (3) provider awareness of verbal and nonverbal patient communication cues. However, in each of the studies examined, there is limited to no research on the influence of an electronic health record on the nurse-patient relationship solely from the viewpoint and experience of the hospitalized patient.

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A qualitative research design was used to explore the patients’ perception of the nurse-patient relationship when nurses use an electronic health record in hospital settings to communicate during patient interactions. A phenomenological approach has been selected to generate knowledge that will enhance nurses’ understanding of the nurse-patient relationship, as experienced by the patient, within the technological healthcare environment. This type of research focuses on the subjective nature of a phenomenon, which cannot be measured using an objective measurement instrument.29–32 Qualitative researchers believe that individuals actively participate in social actions, and through these interactions, individuals come to know and understand phenomena in different ways.32

A phenomenological method was selected for this study because it fosters an interpretation and description of the patient’s experience when nurses communicate with them while using an electronic health record. Heideggerian hermeneutics is a type of phenomenological research that strives to understand and give meaning through interpretation of experience by being in the world.29,32–34

In 1964, Martin Heidegger wrote an essay about the impact of technology.35 In this essay, Heidegger provides an understanding of how an inanimate technological object can move into existence and then into a technological presence. An inanimate object does not have existence but rather is an object in the world. A nurse’s interaction with this computer, using the computer to access an electronic health record, gives this object existence and connection within the world of being.

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Population and Sample

Individuals admitted to a large community hospital were the population and setting from which potential study participants were recruited. A purposeful sample of 11 patients admitted to a hospital with a chronic nonthreatening illness of 1 to 3 years with a hospital stay of 3 to 5 days was recruited to participate in the study. Participants excluded from this study were patients with life-threatening status, isolation status, history of mental illness or combative behavior, and inability to understand written and verbal English speaking communication. Also excluded were patients to whom the researcher had directly provided nursing care in her role of staff nurse.

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The institutional review board review and informed consent process were completed within the researcher’s educational institution and within the community hospital system in which recruitment of participants occurred. Instruments were developed by the researcher, with faculty and colleague assistance, as part of the researcher’s DNP course work. Research instruments used consisted of a demographic background survey and an open-ended interview protocol. The demographic and background survey contained 14 survey questions that identify participant humanistic characteristics and previous computer knowledge in order to further understand participants’ experiences. This survey was also used to establish study participant eligibility. Five questions address gender, age, educational level ethnicity, and employment status. One question addresses length of hospitalization. Three questions address the hospitalization stay and year of chronic illness. In addition, seven questions address computer and electronic health record utilization. The survey was administered, in the patient’s home, prior to the open-ended interview. Readability of the interview questions was confirmed at a sixth-grade level using a Microsoft Word 2007 advance Word option program (Microsoft, Redmond, WA).

Interview questions were carefully worded and arranged with the intent of taking each respondent through the same sequence.36 The research questions are not drawn from any research study but rather developed after a review of the literature was completed. An interview protocol including open-ended questions was used during the post hospitalization home visit. A pilot test of data instruments, member checking, peer debriefing, and a research audit trail were completed to establish authenticity and trustworthiness of the research data.

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Procedures for the data collection process included the following: nursing unit education regarding the recruitment process, recruitment of sample, obtaining written consent, arrangement for an open-ended interview protocol and study survey, completion of both the study survey and open-ended interview protocol, transporting data to a transcriptionist, analyzing interview responses using NVIVO 9 qualitative software (QSR International, Doncaster, Australia), member checking, and writing research findings. Education for nursing staff about the research study and recruitment process occurred within a 2-week period prior to the actual research start date. RNs or health unit coordinators on two medical inpatient units then gave a study flyer to all patients admitted to the inpatient unit. Potential participants were given time to review the material after which the RN read a short script and gave the potential study participant a letter further describing the research study. If a potential participant expressed interest in learning more about the study and was ready for discharge, the RN would then ask permission for the researcher to enter the room.

The researcher then gave a potential participant a verbal explanation of the study’s purpose and goals as well as the consent form describing the research process. Potential participants were also informed of the survey and home interview and human subject rights. The researcher then left the room to allow the potential participant time to read the consent form and synthesize the information presented. If a patient agreed to participate in this study, written consent was obtained by the researcher prior to hospital discharge. After obtaining written consent, the researcher arranged a convenient time for completion of the study survey and interview. The researcher verified interview day and time with the study participant, 1 day prior to conducting the survey and interview.

During the home research study visit, a participant was given the demographic background survey to fill out. After the survey was completed, the researcher quickly reviewed survey answers to verify participant eligibility. If a participant met inclusion criteria for this study, the open interview procedure commenced. All survey information participants who did not meet study criteria or who chose to voluntarily remove themselves from this study was destroyed immediately by shredding.

Study participants were interviewed, in their homes, within 2 to 4 days after hospital discharge date. The day of discharge is usually complex and tiring for a patient, and an interview at that time may add further stress to the discharge. Timing of the interview within 2 to 4 days after discharge was critical in order to capture the patient experience before the memory of that experience fades. Researcher interview notes were written after each participant interview to avoid premature conclusions while still capturing observed behavior. During data collection and analysis phases, the researcher kept a research journal discussing her thought processes, observations, concerns, potential bias, interpretative thoughts, ideas, and thesis committee questions.36,37

The digital audio device was placed in a locked brief case and escorted to a professional transcriptionist who transcribed the data verbatim within a private locked office. All written and electronic data remained in a locked file container within the researcher’s private home office. To protect confidentiality, all identifying participant data were removed from the transcribed interview; individual participants were given a number code known only to the researcher. Data analysis and interpretive writing were entered into NVIVO 9, through thematic interpretation, using Van Manen’s34 data analysis method and aspects of Benner’s38 thematic data analysis approach.

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Participant Survey Characteristics

Responses from the demographic background survey demonstrated that there were 11 participants; six of those participants were male, and five were female. The mean age of participants was 52 years, with an age range of 20 to 78 years. Ten of the participants were white; one was African American. The mean in which participants were first diagnosed with a chronic medical condition was 4.91 years. All participants had completed a high school degree, and the majority of participants achieved a technical or undergraduate degree (n = 8). More than 50% (n = 6) of the participants were retired. Three of the participants worked full time, and two participants were unemployed at the time of the study. A majority of study participants had experience using the computer (n = 10).

Of the 10 participants who used a computer regularly, many used the computer for Internet services (n = 6). One participant did not use the computer. A majority of participants were aware of their own electronic health record (n = 10), with one participant unaware of his personal health data being located within a computer interchange. Five participants had been exposed to the electronic health record prior to this study.

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Interview Protocol Research Themes

Data analysis of interview responses was facilitated by NVIV0 9 qualitative software. Four themes were derived from the NVIVO 9 data analysis of interview questions: (1) presence, (2) respect, (3) knowledge, and (4) safety and trust. A conceptual framework of themes is shown in Figure 1.

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Recent nurse scholars have defined presence as “an intersubjective encounter between a nurse and a patient in which the nurse encounters the patient as a unique human being in a unique situation and chooses to spend himself/herself on the patient’s behalf.”39 Participants expressed an understanding that the electronic health record was essential for a nurse to be able to perform his/her duties. The engagement of a nurse with a participant was viewed in a more positive manner if the nurses first introduced himself/herself and acknowledged the participant as an individual prior to using the electronic health record. One participant described his positive experience when the nurse engaged with him while using the electronic health record.

There was never a break in the conversation, and she could keep an eye on what she needed to look at. I mean it beat fumbling through files, you know? Like they used to have to have a file, and then “Well, hold on a second, I got to turn the page” [chuckles] you know? I mean, everything came up on the screen for them.

One participant conveyed his disappointment when a nurse entered his room and proceeded to the computer without acknowledging or talking to him first.

I felt as though they were probably just doing their job, and I did not take it as some sort of an offense or anything like that. At the same time, there is a certain loss of… [sighs] I don’t really know how to put it, but you, you don’t feel quite as “in touch” with the person you’re speaking with, when they are… clearly… focused on something else that’s happening.

In this research study setting, a computer containing the electronic health record was located in one of two positions. The first computer position was at the head of the bed with the computer facing toward the far wall and foot of the hospital bed. The second position of the computer, containing the electronic health record, was to the side of the bed facing the other side of the bed. The nurse was limited in moving the computer screen to the participant. One participant described how she modified her actions to browse the computer screen while engaging in a conversation with the nurse, regarding her electronic health record information.

Some of them like explained right away, or some of them waited until after they were done entering the information, then they’ll explain it. So it’s kind of both ways. Some turned the monitor so you could see it. Or, I just looked at the monitor when they go over there to type in the information. So, it, I say both ways: either I look at the monitor, or some would just turn the monitor so you could see the information.

Participants voiced either a connection or disconnection within the nurse-patient relationship, depending on whether the nurse explained his/her movements when entering data into the electronic health record. A positive nurse-patient connection was established if the patient was an active partner with the nurse in reviewing the computer screen information.

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Individuals would all agree that respect is morally important. We expect it in our everyday interactions, and physicians, nurses, and patients alike recognize its essentiality to the clinical relationship.40 Respect was described by study participants as the level of regard and merit of an individual. If a nurse first engaged a participant in conversation and then described his/her actions with regard to the electronic health record, the individual perceived a nurse as having a respectful acknowledgment of the participant. If a nurse went straight to the electronic health record, however, without first acknowledging the participant, a perception of disrespect occurred.

Participants expressed concerns that the privacy of personal health information no longer exists in the midst of an electronic health record. Participants also expressed unease with multiple providers having easy access to all aspects of personal electronic health record information.

So, I’m in the comfortable position of being sort of a “plain vanilla patient,” that there’s nothing there that can be abused, don’t know how I would react if there was something that I was embarrassed about, or worried about, or whatever, and I know that person was seeing it every day.

Some participants expressed the lack of individual respect when they perceived being treated as an object instead of a human being.

What they perceived was going on in the room was this interaction between them and the computer, and I was just like an information bank that they had to tap into, to fill all of this information out. The focus on the patient was kind of diminished by this computer, because it seemed as though the nurses who came into my room were a little bit more caught up in filling out information on this computer. I was therefore left to try to ask questions, and ask for other… things like a warm blanket, that kind of a thing, in between questions or after they were done. Because basically what it seemed like was after they got the information filled out on the computer, that was essentially their job. I felt like they were getting ready to “treat” something.

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Participants described knowledge as a comprehension of personal health information and ability to navigate a computer containing an electronic health record. A nurse’s ability to know and locate a person’s health record, a participant’s adaptability to the electronic health record, and verification of health information were subthemes recognized in this research study. Participants expected that nurses were more knowledgeable about a person’s health information because they had complete access to the entire electronic health record. In the traditional paper version of the health record, participants understood if a nurse was unable to locate aspects of the clinical health record. According to study findings, participants expected nurses to be able to articulate their full clinical picture because they had quick access to their electronic health record information.

It did actually occur that we had, uh, that we did have one shift of the nurses that… really had no clue what I was there for. I mean, they were willing to let me get up and walk to the bathroom and everything by myself, kind of thing. So, I’m not sure why THAT wasn’t part of the record? I would say that would have been the only thing I thought that… maybe been, should have been on the record a little more there too, was just the… that they would have known that I had surgery in two places and not just one.

Participants’ expectations of the clinical knowledge and competency of the nurse, within the technological arena, have increased with the implementation of an electronic health record.

Some nurses are more skilled than others in using the computer, bringing information up. Well there was one having trouble she just kept saying, “You know I don’t type well, I’m awfully slow at this.” I’m sitting there thinking, “I hope you’re not putting the wrong information in.” I wanted confidence in her.

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Safety and Trust

The final theme of safety quickly emerged during this research study. Electronic healthcare records pose a concern for participants as the easy access to their personal health information also places them at risk for these data to be used incorrectly by others. Participants also expressed concern that private personal health information such as mental health illness or drug addiction may place them in a vulnerable position or inspire bias in healthcare providers and family members or friends. Safety for and trust in an individual’s personal health data are emerging themes that will require further review and study as participants expressed new healthcare concerns regarding the future and privacy of their electronic health records.

Participants have learned to adjust to the electronic health record within the hospital setting. However, participants expressed increased concern that their personal health information, located in one area, might be incorrectly utilized or used for inappropriate outcomes.

I would say if like there was somebody else in the room, and you didn’t want people to know too much about what’s going on; you only wanted a certain amount of information given out. Some will ask you just to make sure, and I think that’s good, some will just start typing in, or some just is quiet. They should ask you, um, “Do you want me to let this person know your information since they’re in here, or you want to wait ’til they leave and I can come back?”

Probably the background concern that I have and most people have is that this positive thing about creating health records also means it can be misused by insurance companies, I mean we’re all living where we’re debating healthcare, and, and it’s very clear that, that many times insurance companies are there to deny claims, because they’re “for profit.”

Most participants expressed anxiety about the next steps of electronic health record accessibility to clinical data. Participants observed that nurses did not consistently explain how private electronic health information was secured and kept in a private and safe location. In the electronic health record system used in this research study, an electronic health record can be logged into only by user logon and ID. Most of the participants assumed there was a security login and logout. Some participants observed the nurses log in and out, whereas there are others who reported the nurse telling him that that is what they were doing. However, overall, there was an inconsistency in explaining how the privacy of personal health data are kept confidential in this hospital setting. During the interview process, many participants asked about the security and privacy of personal health data in the hospital setting.

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Revisiting Research Themes
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Every participant, in this research study, acknowledged the many advantages and safety features of the electronic health record. Many participants expressed a sense of peace when they acknowledged the safety feature of having their electronic health record information complete, intact, accurate, and in one place. Study participants understood that the utilization of an electronic health record results in nurses spending increased time on a computer accessing their healthcare information. This change in workflow was acceptable, to study participants, as long as the nurses first priority was attending to the patient’s needs or requests. Nurses need to engage the electronic health record in collaboration with the patient, and they must reflect confidence. Participants comprehended that the computer, containing an electronic health record, was a third identity that could distract the nurse from “being there” for the patient. Although participants expressed a number of concerns, they generally acknowledge that an effective and productive nurse-patient relationship can occur when the nurse is using an electronic healthcare record for care.

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Since the creation of the Hippocratic Oath around 400 BC, protecting the privacy of patient health information has been an important part of the physician’s code of conduct. This same code of conduct is required of all RNs as stated in the code of ethics for nurses with interpretive statements.41 The HIPAA of 1996 applies to personal health records and protects the privacy of the information in them.6 Research findings established, during this study, that although all participants were provided information and education regarding HIPAA, many of them (n = 10) did not fully understand protection, privacy, and security of their personal health information. Participants were concerned about inappropriate exposure of their personal health information and personal consequences, such as embarrassment, biased views, or the sharing of private health information with others. This potential exposure gives participants a sense of vulnerability.

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A nurse’s level of ability to navigate and discover a person’s health information within the electronic health record was evaluated by study participants as the level of competence of the nurse. Participants have started to adapt to the electronic healthcare environment by accepting the electronic health record as an object of interchange between them and the nurse. What remains unclear is an exploration of this adaptability component. Are participants accepting of the electronic health record, or is this adaptability resignation to technology? This finding is a new factor that must be added to our understanding of the nurse-patient relationship and electronic health record utilization.

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Safety and Trust

In this study, safety and trust were described as protection of personal health information and increased participant vulnerability with easier access of all personal health information by healthcare providers. Participants were concerned about inappropriate exposure of their personal health information and personal consequences, such as embarrassment, biased views, or the sharing of private health information with others. This potential exposure gives participants a sense of vulnerability.

This research finding is an, immediate and emerging concern expressed by all study participants. Technology is a double-edged sword; participants viewed the completeness of the electronic health record as a main advantage to healthcare technology but worried about where their personal health information will be viewed or sent electronically Table 1.

Table 1
Table 1
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Study Limitations

There are several limitations in this research study. There was limited access to a homogeneous group of individuals. Because participants volunteered to be interviewed, it was extremely difficult to obtain a diverse group of participants. The part of the Midwest that this study was conducted consists of a majority of white and European descent individuals. A further limitation to this research study may have been the high educational preparation of study participants. All participants graduated from high school, with the majority having obtained either a technical or a college degree. It is unclear if study results would have differed with a more diverse group of study participants.

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Suggestions for Further Research

Based on the findings from this research, this study should be expanded to include those individuals whose electronic health record contains the diagnoses of mental illness, addictive behaviors, or any uncomfortable personal information. This study should also be expanded to include a more diverse participant sample as a way to verify findings from this research study. A third implication for further research would be research looking at privacy of health information in the education of participants to the security of their electronic health information. Finally, research needs to be completed in regulation and monitoring of personal health data to ensure that an individual’s personal health data cannot be used in an appropriate and unethical manner.

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Implications for Nursing Practice and Education

As a result of this study, four interactive steps were created to effectively communicate with a patient while using an electronic health record. Use of the four interactive steps, during any computer interchange, resulted in a positive a nurse-patient connection: (1) acknowledge and attend to any healthcare needs as soon as you enter the patient’s room prior to using the electronic health record; (2) explain all movements on the computer including when personal health data are entered; (3) explain the rationale for electronically generated questions and nursing protocols; and (4) acknowledge and attend to any healthcare needs before leaving a patient’s room. Table 2 describes the four interaction steps.

Table 2
Table 2
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It is acceptable for nurses to spend time entering data into the electronic health record in front of the patient without engaging in conversation as long as there is that prior acknowledgement of the patient as an individual. Participants want to observe nurses entering data into their electronic health record, and it is strongly encouraged that nurses complete documentation and the electronic health record in the patient’s room.

Healthcare and technology system organizations need to include the humanistic side of any computer interchange when evaluating or developing healthcare technology. Currently, the meaningful use of technology is being discussed in depth at the national level among healthcare organizations. However, meaningful use in technology also encompasses the patient interaction that must be incorporated into new technology. Healthcare organizations and providers should inform patients when they are logging in and out of the computer and what this logging in and out means to the security of a person’s healthcare data. Further research, regarding safety and trust within the computer interchange, must be conducted to ensure that patients’ rights and privacy are respected and understood by healthcare recipients and providers. Further legislative action may be required to ensure that failure to maintain privacy of personal health records has significant consequences for providers, organizations, and individuals.

Finally, location of the computer screen between a nurse and patient is pivotal to a successful connection with the patient. The computer screen should be facing toward the patient and allow a face-to-face connection between a nurse and patient. Hospitals need to organize hospital rooms so that fixed computers containing electronic health records can be viewed by patients.

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The electronic health record will remain a permanent fixture within our healthcare delivery system. Since the implementation of electronic health records, patients have adapted their communication style to the nurse with the understanding that the nurse now must engage the electronic health record in order to provide care. As we move forward with technology, we must never forget the human connection. As nurses and patients continue to adapt to a technological arena, the theme of safety and trust assumes new importance. Further research keeping the humanistic side of technology in focus will ensure a productive and meaningful nurse-patient relationship within the technological environment.

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The author would like to acknowledge the support and mentoring of this doctoral research project by the following Frances Payne Bolton School of Nursing DNP Thesis Committee Faculty: Cheryl Killion, PhD, RN, FAAN, chairperson; Noreen Brady, PhD, RN. APRN, BC, Member; Christine Hudak, PhD, RN, CPHIMS, member.

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Electronic health record; Patient perception; Nurse-patient relationship

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