Adaptation to Residential Care: Voices from New Zealand

Myunik Panthi ^*

1. Sociology, Gender Studies and Criminology, University of Otago, Dunedin, New Zealand

* Correspondence: Myunik Panthi

Academic Editor: Ami Rokach

Special Issue: Loneliness and Resilience in Old Age

Received: May 25, 2023 | Accepted: November 27, 2023 | Published: December 01, 2023

OBM Geriatrics 2023, Volume 7, Issue 4, doi:10.21926/obm.geriatr.2304259

Recommended citation: Panthi M. Adaptation to Residential Care: Voices from New Zealand. OBM Geriatrics 2023; 7(4): 259; doi:10.21926/obm.geriatr.2304259.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

New Zealand’s population is ageing rapidly. The proportion of the population aged 65 years and over is expected to increase from 16 per cent in 2020 to 21-26 per cent in 2048 and the proportion aged 85 and over is expected to increase from 88,000 to 266,000-318,000 in the same time frame [1]. In 2020, 34,646 older adults were living in residential care and, among them, 55 per cent required the highest level of care [2]. The increased age of the population poses significant issues for providing sustainability of quality care in long term residential care in New Zealand.

New Zealand provides four types of long-term care services to older adults, including rest home care, hospital care, dementia care and psycho-geriatric care, depending on the physical and cognitive abilities of the person. The needs of potential residents are assessed using the International Long Term Care Facilities assessment tool (InterRAI) to inform their care plans [3]. The government provides a residential care subsidy for older adults; however, in order to be eligible for the subsidy, the potential resident’s assets are tested and, only if their assets fall below the asset threshold, do they receive the subsidy [4].

Many studies have examined the issues of relocation and adjustment in later life [5,6]. Transitioning to residential care is a life-changing, traumatic and stressful experience for older people [7,8]; one that challenges their feelings of familiarity and belonging [9,10]. The sudden change of living space from house to room, from freedom to strict routines, from absolute privacy to minimal privacy, and to roles imposed by an institutional context poses significant challenges and may contribute to boredom, loneliness and depression [11]. Older adults are experiencing loneliness in residential care and the COVID-19 pandemic has exacerbated this by lack of social contact due to the lockdowns because of multiple resurgence of the disease [12].

Some studies have highlighted the issues of adaptation as fear or trauma. When older adults are not consulted regarding the decision to move, when decisions are rushed, and when family support is limited, adaptation to residential care life can be frightening or traumatic [7,13]. Active involvement in decision making and pre-move visits are important to ease the transition of older adults to residential care and increase their level of satisfaction and engagement [14,15,16].

Adaptation to residential care appears to progress in stages. Developing new identity in changed living circumstances creates challenges. Most older adults resist the move into residential care [7,13] and actively work to create meaning in their everyday lives despite physical, mental, emotional and social challenges [17]. Brooke [18] describes this challenge into four different stages of adjustment among older adults in nursing homes: disorganisation, reorganisation, building relationships and stabilisation. Similarly, Riedl et al. [19] also identified different stages of adaptation in nursing homes: experiencing change, coping with change, maintenance of autonomy through mobility, developing new identity and wishes and expectations for future.

Leisure activities contribute to successful adjustment and adaptation during the transition to residential care [20]. Activity participation can compensate for social and physical loss, support positive attitudes, and develop a sense of place and sense of self [5,21,22,23]. Affirming self-identity through leisure activities offers a way to cope with the loss of independence, dignity and control that can come with advancing age [24,25,26].

Being in an unfamiliar environment with unfamiliar people causes stress, anxiety and confusion, particularly for older adults with cognitive impairments [27]. Several specific concerns have been identified by older adults moving into care. These include: loss of home, rules and regulations, lack of private space, a feeling of isolation from the outside world, busy staff schedules and cognitively impaired co-residents [14,28,29].

The adaptation process is complicated due to the deteriorating cognitive and physical functioning of older adults. There has been very little research into the perspectives of older adults as to how they adjust and adapt to residential care. This article reports on a study which examined the experiences of older adults living in six residential care facilities in New Zealand. It aims to describe their adaptation processes and coping strategies through their own voices to provide insights into how older adults adjust to the losses and challenges of residential care.

This study takes a qualitative, phenomenological approach towards understanding the adaptation process of the participants. Phenomenology is widely used qualitative research method in different disciplines in understanding the meaning of people’s lived experiences [30]. This study used phenomenological qualitative investigation to understand the adaptation experiences of older adults in residential care facility. Thematic analysis was used to explore meaning from the perspective of the participants and describes the lived experiences of older adults in residential care in their own voices, which is important in order to understand problems or issues from the participants’ perspectives. The main aim of this approach is to develop meaning from the respondents’ stories [31].

2. Data Collection

Triangulated data collection was used to expand the analysis, adding to its depth [32,33] and enhancing its credibility and validity [34,35]. Data were collected from participant observation, in-depth participant interviews and key informant interviews.

Two levels of sampling were applied for the recruitment. First, a random sampling method was used to select residential care facilities. A total of six residential care facilities were selected. After the completion of the selection process, the invitation for participation in the study was sent to the managers of each residential care facility. In the case of the residential facility that declined to participate, another home was randomly selected from the remaining list and the the above process was followed to contact the newly selected care facility.

The participation observation method was used to understand the context of the participants and their community. Participation observation gave me an opportunity to build relationship with the participants and make them feel comfortable to share their stories. Participation observation for eight hours (9 am - 5 pm) was performed in each participating residential care facility prior to the interviews to build relationship. The detailed notes was taken during each observation on the activities happened in both private (residents’ room) and common place (lounge) during Morning Tea, Activity sessions, Lunch, and Afternoon tea. Also, the interactions between residents and staff.

Semi-structured interviews were conducted among four participants from each selected care facility using purposive sampling. The list of the participants who were able and willing to participate in the interview was provided by the manager. The information sheet was provided to each participants and consent form was signed prior to the interview. The assurance was given to the participants about the anonymity and confidentiality of the information. Altogether, 24 participants were interviewed. The participants needed to be aged 65+, living in a residential care facility, could communicate well in English, and were able to give consent to be included in the interview. The study excluded the participants who could not answer the interview questions. The interviews lasted between 30-120 minutes. The interview question was categories into four different categories; personal information, health information, leisure activities and well-being. The interview began with the question when and where you were born?”, “where did you grew up?”, “what brought you to this rest home?”, “how you feel about shifting here?”, “how did you find it when you shifted here?”, “how easy or difficult has it been to adjust to the differences?”, “What makes your life meaningful these days?” A series of probe questions were used when necessary for clarification. The interview was recorded and was transcribed by the researcher to maintain the confidentiality of the participants.

Staff members who were responsible for organising leisure activities in the residential care were recruited as Key informant participants. The manager of the care facility arranged the meeting with the activity staff. The staff were invited to participate in the interview. Once staff agreed to participate the consent form was signed and suitable time for interview was arranged. Ten staff were interviewed from six selected residential care facilities. All the participants were female and the length of their employment varied between 4 and 34 years.

This work was funded by the University of Otago. The study received ethical approval from the University of Otago Ethics Committee (Health). All participants provided informed consent.

3. Data Analysis

The study employed thematic analysis [36] to uncover themes and patterns describing the adjustment process as captured by interviews and participation observation notes. To develop the themes from residents’ narratives, key informant interviews and participant observation, a reading, coding, and re-reading approach was used. The coding and recoding enabled to recognise different patterns within the data and develop the themes. The importance of using thematic analysis method is reflected in its flexibility, transparency, insightfulness and clarity. Data were coded both manually and using the qualitative software NVivo (QSR International’s NVivo 11 software). The first two steps involved; reviewing the lines, sentences and paragraphs from the transcripts and field notes, including participant observation notes and developing initial codes. In third step, each codes were categorised to the broad themes. Codes were organised and reorganised to produce various broad and sub-themes from codes generated in first two steps. Fourth step focused in developing coherence between each theme and the codes. In the fifth step, major themes were relabelled by going back to the initial codes and sub-themes resulting in a comprehensive thematic map. New themes were generated in instances where the codes did not cohere with each other to develop meaning. The sixth step involved writing a report by matching final themes with the research aim to ensure accuracy, consistency and coherence.

The field notes not only enabled me to add rich descriptions of the participants during analysis, but also allowed me to critically evaluate my performance, biases and feelings as an interviewer. The participation observation notes, and accompanying field notes were referred to repeatedly during all steps of analysis. Constant checks, re-checks and comparisons were also completed during the process of the analysis to provide credibility and trustworthiness. The final draft of the themes was given to the supervisors to check and, based on their feedback, the final themes were developed.

4. Results

The age of the participants ranged from 71 years to 94 years, with an average age of 85 years. The majority of the participants were in their 80s and 90s. Among the 24 participants, 16 were female. Twenty participants identified as New Zealand-born European, three participants identified as Scottish and one resident identified as Māori (see Table 1). The length of residency among participants varied, with the majority having lived six months to one year in residential care, some two to three years, and three participants having lived in care for four years or more.

Table 1 Descriptions of participants (N = 24).

The findings of the study highlight the adaptation strategies of participants (see Figure 1). Adaptation to a residential care was a challenging and long process to participants. They required a lot of support and time to accept their life from a home to a room. Four themes emerged from the experience of the participants and staff in the residential care facilities. These include: Loss, Support, Acceptance and Meaningful Activities.

Figure 1 Adaptation Process.

4.1 Loss

Entry into residential care begins with loss. The narratives of both participants and staff revealed that the transition to residential care was always followed by worsening health and hospitalisation. All the participants reported that they did not want to move into residential care. The decision to move was initiated by their doctors and family members and they accepted the decision to avoid the burden to their family.

“My family made the right choice to put me here [rest home] because I needed.” (Janet, resident for 2 years).

“I have been in hospital for couple of times and this time actually [doctor said] no you can't go home you got a come [go] to a rest home.” (Martin, resident for 2.5 years).

All the participants reported that they were devastated with the decision of move in their initial days. They were grieving for the losses and changes that they experienced after their sudden move to the residential care facility. Four participants reported that they did not come out of their rooms initially and it took six months to a year to adjust to their new environment. The sudden move into residential care increases the risk of loneliness and boredom among older adults as they confine themselves to their rooms and lose self-confidence and positivity. Staff also reported that the initial days are challenging for the residents. The first few months is considered as a settling in time for new residents. The activity staff reported that, in initial days, most of the residents isolate themselves in their own rooms without being involved in any rest home activities and they respect their choice.

“I think you know that one day they maybe or might come out and it might take one week, might take two weeks, might take a month but if still we just keep inviting them.” (Activity staff 4, worked for 23 years).

Participants were not only losing their physical and mental abilities, but also their home, belongings, family, friends, community, freedom, autonomy, and identity. These losses confined many participants to their rooms. It was hard for them to accept residential care as their home because they had to fit in and negotiate their needs and desires as per residential policies.

4.2 Support

Changed living environment and culture added substantial challenges for older adults in their adjustment to residential care. Staff and family support was important for many participants during their transition. Seventeen participants reported that frequent visits from family and friends once or twice a week helped them to develop connection and meaning in their life. Connection with the community was important in developing a sense of belonging and easing their transition into residential care.

Ten participants reported that staff support was important because it made tremendous difference in their lives. One of the participants, Sylvia, who took a long time to adjust to residential care, emphasised the significance of staff support. Staff support helped Sylvia to come out of her room and join activities. Similarly, Janet (78 years, resident for 2 years) also explained that carer helped her to overcome with her grief. She took six months to involve in the activities because living in residential care was against Māori culture, in her culture older adults were taken care of at home, not in care facilities. The stories of participants revealed that staff support developed feelings of “belonging,” “respect” and “worth living.”

Staff’s friendly behaviour played an important role in adjustment process. Participants appreciated that staff treated them like their family members, and shared their personal lives. Bridget (87 years, resident for 4 months) said that she felt like staff were like her grandchildren. Similarly, Albert (87 years, residents for 4 months) and William (75 years, resident for 4 years) said that, the staff continuously encouraged them and checked upon them when they were alone in their rooms.

Continuous motivation was important to bring positive changes in the residents. The staff believed her continuous effort motivated a resident to come out of her room to join in the activities after seven months’ residence. Similarly, family support was also important to the participants. Albert (87 years, residents for 4 months) expressed that family support made his life worth despite feeling lonely and helpless “you do get a bit lonely just the satisfaction the way you finish [you live life in residential care] that but then you've got to keep it accepted, you can't do a thing [anything] about it but the family make it a hang of a lot better, make the life worth living still.”

4.3 Acceptance

Almost all the participants expressed their acceptance of the move to the care facility by making the following types of statements: “I am not a complainer” (P. 2, 4, 8, 11, 14, 15, 16, 20), “I take it as it comes,” (P. 7, 18, 19, 21, 22, 24) “There is no point in complaining at this age,” (P. 6, 9, 17) “I am not making a fuss,” (P. 3, 5, 6, 13) “do what has been told to you.” (P. 1, 18, 15, 11) [see Table 1]. These assertions of the participants not only shows the trend of acceptance of their situation, but also reflect the cultural norms in residential care. All the participants applied the strategies of acceptance by not complaining and taking things as they came. In other words, the move into residential care was beyond their control and could not be reversed. Twelve participants reported that accepting the residential care facility as their home was important. Almost all the participants explained challenging in adjusting on their first arrival to the facility. Despite these perplexity, participants had come to the self-realisation that accepting the current living setting would make life easier.

The stories of the participants revealed that older adults are good at compensating for the losses they experience when moving into residential care. The statement by Florence below shows the acceptance behaviour of older adults.

“How would you be if you're at home and you had to go outside and bring in wood and coal to make a fire to keep warm you don't have to do that here isn't that a big advantage.” (Florence, 90 years, resident for 3 years).

The narration of participants highlights the challenges in accepting residential care as their home. One of the participants, Janet (78 years, resident for 2 years), stated it took six months for her to accept the residential care facility as her home. She regretted that she wasted time by confining herself to her room all the time. She said “It’s been a struggle, for the first six months I wouldn’t go out of my room or anything. I just didn’t cope at all”. Edward (75 years, resident for 2 years), however, reported that it was very difficult for him to accept to live in residential care because he misses his home and wife.

“Nobody solved the problem I had from my health. It did take me a while to adjust just stuck in the room on my own most of the time, yes. A lot of machinery and things like that [needed] to move me around and moving from place to place which we haven't got at home and are unlikely to get it home so my chances of getting [back] home back to my wife again is a little bit slim. Occasionally, I get time for [chance to] visit [home] to see her [and meet wife] in a bus that goes out. We have got to hire it [mobility van] and it's quite expensive. Sometimes… it now and again, two three times a year or less to take me home. Once I am at home I don't want to come back here.”

One of the strategies of acceptance among participants was developing a positive attitude. The common acceptance statements among the participants were “getting on with it,” (P. 2, 7, 10, 15) “taking it as it comes,”(P. 17, 18, 20, 23, 24) “making the best of it,”(P. 1, 4, 11, 16) “fitting into it,” (P. 5, 6, 9, 19) “doing one’s best” (P. 3, 8, 11, 13) and “obeying staff.”(P. 12, 14, 19, 21, 22) [See Table 1]. As Helen (94 years, resident for 1 year) expressed, “some things I can’t do of course, but I make the best of what I can.” Similarly, Martin (91 years), Harry (92 years, resident for 2 years) and Jacqueline (75 years, resident for 1 year) and Lawrence (88 years, resident for 4 months) explained living in residential care is definitely different than living at home and accepting the circumstances helps to overcome with the challenges. Albert (87 years, resident for 4 months) states everyone needs to accept their situations “I have accepted, [all that] that all I know that [is] I am just lacking and being in position to be here [residential care]. That's what I think about life because we all gonna accept it.”

4.4 Meaningful Activities

The stories of participants revealed two types of activities in the residential care setting: Self-led and facility-led activities. In many cases, self-led activities developed a sense of purpose and meaning in participants’ lives. Participants described charity activities, volunteer work at the facility, taking care of or helping others, and trying to make others happy as meaningful activities as this gave them sense of purpose and contribution.

Participants managed to develop a connection with different activities available to them at the residential care facility in order to develop meaning in their lives. Some participants managed to reframe their past activities. The participants’ narratives revealed that getting involved in activities was something that they felt was important in retaining their autonomy and identity. Some participants were able to retain their nurturing role by looking after other residents in the facility. However, others felt there was no opportunity for interaction as their co-residents were cognitively impaired and unable to hold a conversation.

Despite worsening health conditions, many participants described that they kept them occupied with activities such as bird watching, sitting in the sunshine, or listening to music:

“I used to do gardening but I couldn't do gardening anymore. So, the gardening gone but I see the flowers grow up and now I am used to it.” (Helen, 94 years, resident for 1 years).

Three participants described how helping co-residents had provided them with the motivation for adjusting to their move. Florence (83 years) explained her nurturing/caring role helped others to get involved in activities.

See I'm a terrible woman like that I take people into things [activities] but he didn't seem to want to [participate] you know but we all knew that, we all know it's hard when you first come into rest home to feel at home. (Florence, 90 years, resident for 3 years).

Nine participants expressed that the facility led activities were boring and they were not interested in them. Ten of them reported they did not participate in the ongoing activities as they were happy on their own and with their visitors. Almost all participants reported that the activities they were involved in were different than the activities they participated at home. Elizabeth (83 years, resident for 3.5 months) states “Yeah, they [activities] are very different then that we used to do at home. It is limited.”

Five participants managed to continue with the same activities they did before in some form. Two participants reported mixed opinions - they participated in to fill in time but those were not of their interests:

A little bit awkward here because there is not a lot of a thing [activities] here. I would be doing at home or everything I would be doing at home are different from what I am doing it here. It's just something to fill the time that's all, yes. There is not much else [activities to participate]. (Edward, 75 years, resident for 2 year).

The activity staff also reported that the majority of the residents preferred to sit in their room than participating in the facility led activities. Furthermore, they asserted that the residents needs individualised care, attention, and enjoyment in their later life than the activities:

They [residents] have never been sitting out [in the lounge] with the whole lot of people, they might like to sit in their room and knit like one lady up stair sit and read, do crosswords and [she is] very happy in doing that. So, we have to respect their individuality because that's what is [all] about as well. Umm... it's not a compulsory things for the people to join the activities that we provide. (Activity Staff, 1).

The participants who actively engaged in the activities also helped other co-residents to adapt. In one residential care facility, staff reported that a group of female residents took special care of the new residents and helping them to get to know the people and place.

5. Discussion

This study explored the adaptation process of older adults in residential care in New Zealand. The findings highlights that moving into residential care was traumatic, resulting into multiple loss and poor well-being. The process begins with a grieving period as new residents adapt to various losses. During this process, loneliness and boredom becomes prevalent among residents due to pervasive loss for example home, family, friends, independence, support and freedom. The transition begins with grieving their major losses and ends with accepting the residential care facility as their permanent home. In this process, the participants told stories of loss and medical emergencies that shaped their journeys from their own homes to residential care. Participants not only experienced the onset of frailty, but they also encountered a range of challenges during transition. As a result, they saw their lives in different forms: as a loner, dependent, passive, receiver, and isolated. Having control over their lives, meaningful participation and socialisation were the key aspects of adaptation. Unplanned admission to residential care may lead to poor adaption and poor well-being [8].

Institutionalisation, pervasive loss and routines poses significant challenges. The new environment threatens a person’s existence and disrupts the sense of control over one’s own life [27]. The findings provide insights into how a threatening new environment can be changed into a friendly environment for residents. Older adults continually work to retain their existing identity. Home was central to the participants’ narratives - loss of home resulted in loss of independence and continuity.

Participants had difficulty accepting the residential care facility as home despite the efforts of staff to develop a home-like environment. This finding is consistent with previous studies (i.e. [10]), in that physical environment is crucial in developing a sense of home. Many studies have highlighted the importance of developing sense of home in residential care as an important component of well-being in later life [14,27,37,38]. The challenges identified by the participants in this study are similar to those identified by Jaye et al. [29] and Kiata-Holland [17]. Along with physical environment, satisfying social and emotional needs is important for older adults.

However, other residents took time to adapt in residential care setting. Fewer opportunities, individual choices, poor social support and lack of interaction are problems associated with poor well-being, as these factors increase the risk of loneliness and boredom in residential care [39]. The participants reported that they took time to come out of their rooms in their initial days at the residential care facility because of lack of feeling of home. In order to address these problems, the policy still needs to be revised to remove routined/custodial body care to individualised care. Despite implementation of person-centred care, residents stories shows lack of person-centred care. Introducing resident-based programmes is important to focus on meaningful participation rather than fitting residents into existing programmes. The findings revealed a mismatch between residents’ expectations and the service delivered in residential care.

The narratives of residents and staff revealed the tension in meeting the leisure, social and emotional needs. Residents had to fit themselves into staff routines and staff had to meet the organisation’s policies and strategies. The findings of this study highlight the importance of developing flexibility in caring culture to meet the diverse needs of older adults and to help them avoid the feeling of having no control over their life. This findings is consistent with Forsund et al. [27].

Developing a positive attitude despite multiple illnesses and losses, and accepting the offered services seemed to be the adaptation strategy among older adults in residential care. However, the lack in offered services to meet the leisure needs can put residents at risk of loneliness and boredom [39]. The adopted strategies of participants provide an example of how simple and small things were meaningful to them. Participants selected activities based on their functional abilities in residential care. The Gardening activity was altered by walking around the gardens, touching the plants and picking flowers, and arranging flowers at the dining tables. Similarly, visually impaired older adults adjusted their activities from reading a newspaper/book to listening to the news on the radio. Thus, the stories of participants revealed their adaptability and resilience.

The findings illustrates the significance of offering ample leisure opportunities through an individualised approach [17,40,41] in easing the process of grieving and adjustment in residential care. Participation in activities that offered social interaction, such as outings with family and friends (e.g. going to the cafe, beaches and shopping) helps in maintaining a sense of identity and meaning to older adults and helped in their adjustment process and also minimises their feelings of loneliness and boredom. According to Osterlind et al. [42], the loss of one’s own home is a situational transition and older people are vulnerable during such a transition, as it threatens their identity and creates a feeling of loneliness. This is also one of the key findings of this study, in that older adults work hard to retain their existing identity. They need extra support in their first few months in residential care to ease their transition by helping them to avoid loneliness and boredom.

Along with other studies, this study also highlights the problems associated with adaptation to residential care. It suggests developing robust plans to identify gaps in service delivery (regardless of the existing person-centred approach) and thereby avoid the problems of adaptation in residential care. This study suggests developing strategies that contribute towards residents’ feelings of sense of place, attachment, identity and connection in order to ease the process of transition and adaptation in residential care.

This study has both strengths and limitations. The phenomenological perspective facilitated the description and interpretation of the experiences of older adults to provide new and important contributions to the field. Describing people’s lived experience is fundamental in understanding multiple meanings to their lives. The data were collected from only one city in New Zealand, so the transferability of findings may be limited. However, the information collected from the six different residential care facilities provides valuable insights into what influences residents’ adaptation processes. Additionally, the study excluded severely cognitively impaired residents. Further study should include data collection from family members of such residents and the staff who work with them to gain multiple perspectives on adaptation process. The COVID-19 pandemic has added more restrictions in residential care facilities and further research is essential understanding adaptation among older adults in residential care related to the COVID-19 pandemic.

6. Conclusions and Implication for Practice

The study found that initially the adaptation process was challenging and traumatic to the older adults due to unplanned move. The adaptation process was eased by the support of the family and staff support, encouragement and self-led leisure activities than facility led activities. Given this, it is vital to plan the move in advance and offer a range of suitable leisure opportunities in order to ease residents’ adaptation process and support their well-being by avoiding loneliness and boredom. The stories of participants in this study revealed how older adults seek meaning in their lives through human connections and simple activities (e.g. watching birds, touching plants in the garden, listening to the radio), despite physical and cognitive limitations.

A person’s identity is important in giving meaning to their life. Supporting older adults to find the ways to retain their existing identity or develop a new identity is important. The sources of adaptation and resilience pointed out in this study may have practical implications for enhancing the well-being of older adults. Conversations about moving to residential care and advanced planning need to be given space while supporting older adults at home to avoid the trauma of a sudden move. The efforts needed to be made in collaborating with community organisations or day care centres to foster bonding between older adults in the community and residential care facilities. Collaboration between policymakers and residential care managers and activity staff is important in developing programmes which are meaningful to residents and which ease adaptation and reduce loneliness and boredom in residential care facilities. More research is needed in residential care settings to better understand how to support older adults during transition and adaptation.

Acknowledgments

The author wishes to thank all the participants who generously offered their time during the interviews.

Author Contributions

The author did all the research work of this study.

Funding

This work was funded by the University of Otago.

Competing Interests

The author has declared that no competing interests exist.