Journal of Nursing & Patient CareISSN: 2573-4571

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Research Article, J Nurs Patient Care Vol: 1 Issue: 2

Process of Building Patient-Nurse Relationships In Child And Adolescent Psychiatric Inpatient Care: A Grounded Theory Approach In Japan

Akiko Funakoshi1*, Atsuko Tanaka2, Kie Hattori3 and Minori Arima4
1University of Hyogo, College of Nursing Art & Science, Akashi, Hyogo, Japan
2Nihon Fukushi University Nursing Practise and Research Center, Tokai, Aichi, Japan
3Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Aichi, Japan
4Hong Kong Japanese School Primary Section, Hong Kong
Corresponding author : Akiko FUNAKOSHI
University of Hyogo, College of Nursing Art & Science,13-71 Kitaoji-cho, Akashi, Hyogo 673-8588, Japan
Tel & Fax:
+81-78-925-9420
E-mail: [email protected]
Received: August 22, 2016 Accepted: September 23, 2016 Published: September 30, 2016
Citation: Funakoshi A, Tanaka A, Hattori K, Arima M (2016) Process of Building Patient-Nurse Relationships in Child and Adolescent Psychiatric Inpatient Care: A Grounded Theory Approach in Japan. J Nurs Patient Care 1:2.doi:10.4172/2573-4571.1000106

 

Abstract

Objective: The objective of the present study is to describe the process of building closer patient-nurse relationships in child and adolescent psychiatric inpatient care. Nurses play important roles in psychiatric inpatient care for children and adolescents, and their care can affect every facet of their daily life. The efficacy of treatment depends on the nurses’ ability to build intimate patientnurse relationships.

Methods: A qualitative methodology, based on the tenets of grounded theory approach, was taken. Semi-structured in-depth interviews were conducted with 18 expert nurses and analyzed using a constant comparative method.

Results: ‘Developing emotional attachment’ was identified as the core category, substantiated by four interrelated stages: ‘Becoming a target of attachment’; ‘Forming an attachment’; ‘Expanding the target of attachment’; and ‘Preparing to be a target of attachment’. We found that in developing emotional attachments with inpatient children or adolescents, expert nurses achieved a balance between appropriate psychological distance from - and their own increased attachment to - those inpatients.

Conclusions: The “expert” nurses become a target of attachment for their patients and then successfully extend that to other nurses during professional nursing intervention.

Keywords: Therapeutic relationships; Child and adolescent psychiatric nursing; Inpatient care; Grounded theory approach

Keywords

Therapeutic relationships; Child and adolescent psychiatric nursing; Inpatient care; Grounded theory approach

Introduction

The mental health of children and adolescents is a crucial issue faced by many countries, being also intimately connected to social problems such as juvenile crime, child abuse and suicide. In fact, mental disorders affect 10-20% of children and adolescents worldwide [1], and current global epidemiological data consistently reports that up to 20% of children and adolescents suffer from disabling mental illnesses, and suicide is the third leading cause of death among children and adolescents, and up to 50% of all adult mental disorders have their onset in adolescence [2].
The mental health of children and adolescents is also an important issue in Japan. According to results of a survey of patients released by the Ministry of Health, Labour and Welfare [3], there are more than 226,000 patients under 20 years of age who suffer from mental disorders in Japan, and that number has increased 1.9-fold in the last decade. The promotion of children’s mental health is a high priority policy issue in the Japanese government.
There is strong evidence that it is of benefit to societies to deal with the mental problems of children and adolescents early. As many disorders begin in childhood or adolescence, interventions aimed at early detection and treatment can be assumed to help reduce the prevalence or severity of primary disorders, and prevent the subsequent onset of secondary disorders [4]. Early intervention and prevention offer the hope of avoiding later adult mental health problems as well as improving personal well-being and productivity [1].
Worldwide, inpatient treatment is a complex intervention with the most serious mental health disorders in child and adolescent psychiatry. The disorders with the highest prevalence are psychological developmental disorders, eating disorders, and affective disorders [5]. While the majority of children with mental health problems are treated by community services, a comprehensive child and adolescent mental health service (CAMHS) needs access to highly specialized provision, including in-patient facilities (e.g. a tiered model of service [6]). In Japan, inpatients in child and adolescent psychiatric wards have experienced a wide variety of serious domestic problems prior to admission (e.g., outpatient treatment-resistance, acute psychological deterioration, self-injury, domestic violence and long-term social withdrawal). According to the report of a leading Japanese hospital for the treatment of children and adolescents with psychiatric problems, the most common disorders were obsessive-compulsive disorder and eating disorder, followed by pervasive developmental disorder, and the average length of inpatient stay is 11 months [7].
There is considerable demand for inpatient care and some evidence for its effectiveness exists: a meta-analysis, a review [8-10]. The therapeutic effectiveness of inpatient care was evaluated by measuring the general functioning of children using the Children’s Global Assessment Scale (CGAS). A large-scale UK study points to the 12-point improvement in CGAS and this improvement was sustained as recorded at the 1 year follow-up [11]. Likewise, a Japanese study also revealed that CGAS showed improvement during inpatient treatment in comparison of baseline score with discharge score [7].
Nurses play important roles in psychiatric inpatient care for children and adolescents, and their care can affect every facet of the patients’ daily lives. Indeed, Pedrini et al. claims that about half of treating staff are nurses [12]. Psychiatric nurses deal with a great variety of symptoms and problems in their clinical practice [13]. In fact, our previous research in Japan illustrated 7 care domains in child and adolescent psychiatric inpatient nursing; one-to-one interaction, violence intervention, holistic assessment, support for school attendance, family support, group therapy, team care [14].
In child and adolescent inpatient psychiatric care, the efficacy of treatment depends upon the nurses’ ability to build intimate patientnurse relationships. The quality of therapeutic relationship has a large influence on success of any interventions with children and families [15]. Nurses are trained to have good interpersonal skills [16] because positive therapeutic alliance is one of the predictors of better treatment outcome [11,17]. In Japan, a review reported that nurses are required to establish a trusting relationship with child and adolescent patients [18]. Moreover, Funakoshi et al. suggested that nursing interventions would greatly improve the quality of care, if they built more intimate relationships with their patients [19]. Kato et al. also demonstrated that nurses regarded establishing patientnurse relationships of trust as the most important factor in child and adolescent inpatient psychiatric care [20].
While importance of patient-nurse relationships is widely recognized in psychiatric nursing, it has not been effectively utilized for patient outcomes because it has been difficult to define and operationalize. Peplau emphasized the nurse–patient relationship as the foundation of nursing practice, and described the phases of the therapeutic relationship in her Interpersonal Relations Theory [21,22]. Some previous research, however, have indicate that the grand theory becomes too unwieldy to use and attempts at an all-encompassing definition are problematic [23,24]. Dziopa and Ahern explained the reason was that the construct of the therapeutic relationship was elusive and diverse [25]. In addition, Clark stated a universal theory of the ‘therapeutic relationship’ is not possible because nurses practice in so many different environments [23].
The substantive theory which addresses child and adolescent inpatient psychiatric care is required for enhancement quality of patient-nurse relationships and achievement patients’ outcomes. Relationships with child and adolescent patients differ from those with adult patients and nurses build relationships in a different way with adults. Zack et al. clarified that the therapeutic alliance operates differently from adult for youth and stated that it was necessary as a further study to understand how the alliance develops and what role it may play in treatment process for youth [17]. Therefore, the aim of the study is describe the process of building closer patient-nurse relationships in child and adolescent psychiatric inpatient care.

Methods

A qualitative methodology, based on the tenets of grounded theory approach was considered most appropriate to the study of the process of building patient-nurse relationships because it constitutes an interactive process between patients and nurses [26].
Participants
The participants were “expert” nurses who have more than 3 years experiences in child and adolescent psychiatric wards and were recognized as “expert” by their managers. They were directly recruited by the researcher after their managers, who agreed to cooperate in the present study, introduced them as recognized experts. We intentionally selected participants in various socio-demographic characteristics according to theoretical sampling.
In accordance with the sampling technique of grounded theory, the selection of participants was based on an emerging core category and a conceptual framework. Saturation, a sense of closure in the core category, was reached after 18 interviews.
Data collection
We conducted face-to-face, in-depth, semi-structured interviews with child and adolescent mental health nurses. They were audiotaped and later transcribed in full. The interviews lasted between 61 and 117 minutes (mean duration: 83.9 minutes).
The interviews were focused on clinical episodes of child and adolescent mental health nursing. The interview guide included experiences of both good care and not good care, contributing factors in success of care, evaluations of patient-nurse relationships, and demographic data. The focus of the interviews and the topics to be pursued in subsequent interviews were identified, and participants who were suitable for further interviewing were intentionally selected with various socio-demographic characteristics after each interview according to theoretical sampling.
Ethical considerations
The research protocol was approved by the ethics committee of the university. All participants were informed orally, as well as in writing, about the study’s purpose and methods. They were assured that neither they nor their places of work would be identified. They were also informed that participation in the study was voluntary and that they could terminate it at any time, if they were unhappy with any aspect of it. Written consent was obtained.
Data analysis
Data collection and analysis occurred simultaneously in a constant comparative manner [27]. The transcripts were coded line-by-line using the nurses’ actual words to analyze and describe the process of building patient-nurse relationships. Codes were continually compared in order to identify similarities and differences, and similar codes were integrated. Categories were produced, and characteristics of concepts identified, by repeating the classification and the integration of codes. The interviews were conducted until no new categories were identified. The relationships among the categories were examined by subsuming and abstracting categories, and the conceptual framework was modeled, based on care given to establishing good relations between patients and nurses, and on factors related to this relationship.
The successive memos were created for initial category development and theoretical abstraction and synthesized this constant comparative analysis. Diagramming, including the creation of concept maps and matrices, helped define and refine the relations between categories.
Rigor
Credibility and dependability were established by the following methods: (i) prolonged involvement: prolonged engagement in the field and the persistent observation that occurred in this study over time; (ii) member checks: group of child and adolescent psychiatric inpatient nurses including two of which were participants reviewed all emergent concepts, and subcategories, and categories were deem accurate representations of their experience; (iii) peer debriefing: we made double code transcripts and discussed the interpretation of the data until consensus was achieved over the study.
All interviews and analyses were conducted in Japanese. For the purpose of this report, interview data were translated into English. To ensure accurate translation, translated text was proofread several times by native English speakers.

Results

Participants in the interviews (18 nurses) were: 3 males and 15 females, ages ranging 28–48 years (mean age: 34.8 years) with 3-15 years of experience of child and adolescent psychiatric inpatient care. Six nurses had experience in psychiatric care for adult patients, and three had experience in pediatric wards. The child and adolescent mental health nurses practiced at 4 hospitals in different cities in Japan.
‘Developing emotional attachment’ was identified as the core category. This core category was substantiated by the following four interrelated stages: (1) ‘Becoming a target of attachment’; (2) ‘Forming an attachment’; (3) ‘Expanding the target of attachment’; and, (4) ‘Preparing to be a target of attachment’. To develop an emotional attachment with a child or adolescent patient, nurses must achieve a good balance between appropriate psychological distance from -and their own increased attachment to- the patient.
Becoming a target of attachment
The nurses consciously tried to become both an important figure for and a supporter of the children. However, this resulted in the children’s psychological distance becoming unstable. As the nurses became a target of attachment for specific children, they then had to be careful about maintaining an appropriate psychological distance.
Becoming an important figure
Becoming a target of attachment signified that the children saw their primary nurse as their important figure. In order to proceed with nursing care, it was also necessary for those nurses to become an acceptable figure, and to provide safe and secure environment for the children. Indeed, as one nurse explained about the role of the primary nurse:
“It’s a big deal to be an important figure for the children because they have been separated from their parents for a long time. Of course we don’t think of taking the place of their parents, that’s not our intention; but, It’s like, ‘While you are in the hospital, let me know if you need anything.”
Becoming a supporter
Primary nurses always try to be right behind their children even if they have to deal with very problematic behavior. One of the nurses said:
“Although I can scold the children when they are having behavioral issues, as the primary nurse, I want to gain their trust, so I never want to nag at them too much. If everyone were to be really strict, the children would be up against the wall.”
Not taking the place of a parent
In child and adolescent psychiatric inpatient care, patients sometimes require nurses to provide surrogate parenting. When the children looked for a parental-like relationship with their primary nurses, the latter sought to maintain their role as nurses, they would not become the parents themselves, and they intentionally avoided becoming substitute parents.
One nurse seemed obsessed with the image of “what a parent should be like,” and adopted a negative attitude toward a child’s mother. As a result of emotional attachment to the child, she said:
“I felt my child’s real mother was very cold to her son with a developmental disorder. I was angry. She is a mother, why does she do nothing for her child? Then, one coworker told me ‘You’re more of a mom than the actual mom,’ and I thought ‘Oh, that’s not good.’ I realized that at that time, I had overstepped my boundaries as a nurse.”
Forming an attachment
Nurses who were subject to attachment become so by showing love to the children. Even with their busy schedules, these nurses emphasized the value of one-to-one interactions and conducted constant observation. Based on whether or not the children sought interactions with the nurses, assessments were made by primary nurses regarding the children’s attachment formations. When the children were able to form typical attachments, the nurses engaged the children in solving problems together. The nurses and the children were then able to deepen their mutual affection. But, in order to maintain the stability of an appropriate psychological distance, as a nurse, they had to practice their nursing only on individual bases, with the authenticity of their attachment drawing on their individual personalities.
Showing love for the children
In order to form an attachment to the children, it was necessary for the nurses to feel love for, and be affectionate towards, children. The act of a nurse showing love for their patient is unique to child and adolescent psychiatric nursing, which treats the psychological problems of children in the process of growing and developing. One nurse said:
“I believe patients need love, especially developing children, through interacting with adults. We can say it’s a part of growth. We wouldn’t say ‘Love’ in nursing for adult patients. But working in child and adolescent psychiatry for many years, I have been affectionate with patients.”
Engaging in one-to-one interactions
Many nurses consider that it is important to take time for “oneto- one” interactions with children in order to form an attachment to them. One nurse stated that she proactively made time, even during her busy day, to do so:
“In order to construct a relationship of mutual trust, I schedule time to listen to the children and have a one-to-one conversation. Even if a child doesn’t necessarily have to say ‘I want to talk to you’, I proactively make time to talk to them as much as I can.”
Conducting constant observations
The outcomes of care depend on the quality and level of nursepatient relationships. So, even when busy with other work, or attending to other children, the primary nurses should keep a constant eye on the children they are responsible for. Just as one nurse said:
“As for the children I’m responsible for, I’m ‘watching’ them when they’re on the same floor; I’m actually observing them, because I feel inclined to watch their every behavior.”
Assessing attachment formations
The nurses made assessments regarding their attachment formations with the children. When making the assessments, the nurses focused on whether or not the child was the one to initiate the first interaction. Nurses assess the forming of a stable attachment from consideration of the approach from the child, expressing his/ her concern to the primary nurses, and effectively coping with it. As a nurse pointed out:
“The two children that I’m responsible for are very different; I have established mutual trust with one, but not with the other. I guess it just depends on whether the patient wants to talk. I sometimes really wonder if the child actually intends to get involved with me.”
Engaging the children in solving problems together
After children have formed attachments, the nurses are able to effectively engage the children in solving problems together. Nurses thought that solving problems together also deepened the attachment. One nurse noted,
“When they start talking more about specific concerns, like ‘I’m actually a little worried about this. What should I do?’, then I make suggestions about it. And the child replies ‘Ok, I’ll try that’. Building on such successful talks deepens mutual trust with the nurse.”
Practicing individual nursing
In order to maintain an appropriate psychological distance as a nurse, the nurses tried to interact naturally with the children, but based on their own values. Practicing nursing without stress or strain was considered proper and associated with good care. One nurse talked about the difficulty of having a shy personality as follows:
“I’m not very good at talking to people, so when I do something that I’m not good at, I feel strained. And I try to communicate with the children naturally, because my strained feeling has some influence on their care.”
Expanding the target of attachment
After forming an attachment to their primary nurses, the nurses then tried to help the children form attachments to the other nurses, too. First, they decided to gradually include other staff members in the children’s care. Next, they provided a team-based approach in which they shared their understanding of the children and dealt with them in the same way. Also, they supported the children, so they would be able to trust other staff members and solve their problems with their help, as well. They believed that children expand their relationships based on attachment with their primary nurses who thus serve as a security base for the children. These nurses were able to form affirmative feelings toward the children, in consequence of achieving appropriate psychological distance and emotional attachment.
Including other staff members
The primary nurses gradually included other staff members in the children’s care. One nurse gave an example of how she gradually got her young female-patient to express her own concerns with other staff members.
“If she was able to talk to me about what disturbed her, I would advise her to express her concern to other staff members, too. And I said, ‘We all help you to deal with your concern together, as team care.’ ”
Encouraging the children to solving problems with other staff members
After the children learned to trust other staff members, the nurses then encouraged their children to solve their problems with the other staff members’ support. The children tried and developed their skills of problem-solving with assistance from various adults who they gave their trust to.
“The children tried to solve issues as they emerged with the support of nurses who were there.”
Forming affirmative feelings toward the children
The nurses that were able to practice individual nursing and maintain an appropriate psychological distance from the children, without taking the place of a parent, were then able to form affirmative feelings toward the children. Thus, nurses were able to be affectionate towards the children, acknowledge their development, and see their potential. One nurse said:
“When you get a good sense of distance from the children, you can interact naturally without being conscious of the distance. That’s when you start developing affection towards the children, and I feel like that’s evidence that the nursing care is actually working.”
Preparing to be a target of attachment
When the children began to increase the number of their targets of attachment, the nurses had to be prepared to be subject to new attachments. Four aspects of care were performed: watching over the children, creating a fun environment, playing with the children; and, having an understanding of proxemics and haptics. Without this, care suffers.
Watching over the children
Many nurses conveyed to the children that they were being watched by the entire staff, and not just by their primary nurses. One nurse talked about what it meant to indicate that she was indirectly watching over them, even when working at the Nurse’s Station.
“Even when I’m sitting at the Nurse’s Station, I always try to face outside; so when the children walk by and look inside, I quickly look up so I can catch their gaze. I want them to feel that sense of security and the feeling that they aren’t alone and we are watching them.”
Creating a fun environment
A fun atmosphere helps the children to relax and optimizes interaction with the nurses.
“We make it so that the children are able to relax and talk freely, about their life at home, what they want to do in the future, things that they like, and so on. We try to have casual chats.”
Playing with the children
It is one of the common strategies in child and adolescent psychiatric nursing to deepen relationships with children through play. Many of the nurses indicated the significance of playing with the children in their cognizance of care.
“One day the children wanted to play kickball, so we all went out to the field. The staff members always participate too, and not just the children.”
Having an understanding of proxemics and haptics
The effectiveness of having an understanding of proxemics and haptics, such as staying by the children’s bedside before bedtime, to alleviate the children’s concerns, was talked about.
“Around bedtime, some of the children start crying, because they are homesick. We talk about how their day went, and what they did, and stay by the child’s bed.”

Discussion

‘Developing emotional attachment’ was identified as the core category. It means that building patient-nurse relationships in child and adolescent psychiatric inpatient nursing is the process of developing emotional attachment. Emotional attachment is an affective bond and is reflected in behavioral patterns. From a child and adolescent mental health perspective, emotional attachment is associated with problems in psychological adjustment [28,29]. Indeed, several population studies have already clarified that insecure attachment styles were associated with increased mental symptoms [28]. Findings of the present study indicated that developing emotional attachment is the foundation of nursing practice.
Developing stable emotional attachment to the nurse in child and adolescent psychiatric inpatient setting could lead to patients alleviating distress and acquiring the proper behavioral pattern. It is clear that changes in attachment style are legitimate concerns. Initially, in Bowlby’s Attachment Theory the functions and dynamics of the attachment behavioral system are thought to be virtually the same throughout life, that is to say mother-child relationship quality predicts the quality of every other relationship [30]. Bowlby also theorized however that the attachment behavioral system may be flexible and open to some degree of modification in the context of disconcordant interpersonal or attachment-related experiences [31].
The recent research has demonstrated this potential for change in attachment. It is surmised that attachments form independently of maternal attachments. In early childhood, the quality of infantcaregiver attachment is independent of both maternal and paternal attachments [32,33]. In school age, maternal relationships can be nonconcordant with child - teacher and child - caregiver relationships [33,34]. During adolescence, a new way of forming attachment develops, wherein the transition from childhood into adolescence for most boys and girls is marked by a change in dependence, from parents to peers. It is not seen as straight forward [35]. While research has identified interpersonal and environmental contexts that predict change in attachment patterns, significant changes in the caregiving environment might necessitate modifications in attachment behavioral systems.
The first step to developing emotional attachment is ‘Becoming a target of attachment’. The nurses in this study consciously tried to become both an important figure for and a supporter of the children. They try to provide a secure base in attachment theory. A patient being separated from the primary attachment figure causes feelings of loss and insecurity, and creates attachment needs [36]. The research assumes that the role of care-giver for children are responsible for keeping the child physically and emotionally safe in the absence of the parent such that developing close relationships is an important role of a nurse providing care throughout staying at hospital [30]. Therapeutic relationships are essential to the provision of safe and secure environments and to enhancing the effectiveness of nursing care for children and adolescents.
The next step is ‘Forming an attachment’. The nurses noted that they and the children were able to deepen their mutual affection, and they also maintained an appropriate psychological distance as a nurse. To develop a close relationship with a child or adolescent patient, nurses must achieve a good balance between appropriate psychological distance from -and their own increased attachment tothe patient [37]. This issue appears similar to professional boundary, which regularly arises in psychiatric nursing with adults and can present difficult dilemmas for nurses. However, the professional boundary is an essential component of the therapeutic relationship that allows work to be done in a space that is safe for both the client and the mental health nurses [38].
In child and adolescent psychiatric inpatient nursing, considerable care should also be taken with professional boundary. Some young patients require nurses to provide surrogate parental relationships in care settings, or are not interested in nurses at all, because they have not often developed stable and secure attachments to their parents. Alternatively, nurses are likely to misconstrue the depth of emotional attachments and maintain inappropriate psychological distance to patients. Hence, patientnurse relationships are prone to instability.
Lastly, in this study, nurses extend the range of such attachment across the nursing staff in psychiatric inpatient care. Simultaneously, they had to be prepared to be subject to new attachments when the children began to increase the number of their targets of attachment. They provided a team-based approach in which they shared their understanding of the children and dealt with them in the same way. Children were able to feel safe and secure among the nursing team, and it served as a trigger to therapeutic environment. Berry stated that the attachment system determines the individual’s approaches to seeking help during periods of psychological stress [39]. Expanding the target of attachment could suggest that the children modified their attachment behavioral systems, and they could manage their difficulties. Thus, in child and adolescent psychiatric inpatient care, nurses achieve care outcome through the process of ‘Developing emotional attachment’ as the foundation of nursing practice.
Moreover, nurses should begin extending the emotional attachment which has been developed with children to interdisciplinary clinical team. To expand the attachment to an interdisciplinary clinical team means to seamlessly expand the safe and secure environments for the children into community care settings; therefore, nurses have to liaise closely with other mental health professionals. Many reports emphasize that services from multidisciplinary and multiple agencies are necessary for children and adolescents with emotional and behavioral problems [28,40,41]. Developing emotional attachments, not only in inpatient care units but also to inter-disciplinary clinical team, might be challenging for nurses. It is not sufficient for nurses only to satisfy their patients’ needs by seeking to improve their symptoms and behavior.
Study Limitations
The present study examined the process of building closer patient-nurse relationships with interview data. The process is based on participants’ assessment of the nature of the care. So, we can’t completely deny the possibility of differences in the process of actually clinical practices. Any future participant-observer study must necessarily seek to validate such assessments.
It should also be noted that the results of this study may be affected by the conditions of mental health care in Japan, which has seen an increase in the number of children and adolescents receiving inpatient care for developmental disorder [42]. Furthermore, this study did not examine the impact of the differences in background factors such as age or diagnosis. Further research would benefit from evaluating how the relationship-building process varies according to such factors.

Conclusion

During professional nursing intervention, we found that “expert” nurses become a target of attachment for their patients and necessarily extend the range of that to other nurses. Although the present study has some limitations, it is the first study to clearly describe the process of building patient-nurse relationships in child and adolescent psychiatric care from the aspect of attachment. In conclusion, while it is necessary to develop a close attachment with patients, it is also necessary to engage with inter-disciplinary clinical team at an earlier stage of inpatient care. It is hoped that these findings can contribute to enhancement in the quality of patient-nurse relationships in child and adolescent psychiatric care.

Acknowledgments

I would like to thank participants in this study. I would also like to acknowledge the assistance of L. Pikus, who assisted with the editing. This study was supported in part by Grants-in-Aid for Scientific Research from Japan Society for the Promotion of Science (No. JP22792279). No conflict of interest has been declared by the authors.

Grants or other financial supporters

This study was supported in part by Grants-in-Aid for Scientific Research from Japan Society for the Promotion of Science (No. JP22792279). The authors do not have any conflict of interest with respect to this publication.

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