Four disciplines and a national program. Lessons from a collaboration to strengthen a palliative care simulation–based learning experience (SBLE)

Ms Kylie Ash1, Mr David Klug1, Mr Nathan Reeves2, Distinguished Professor Patsy Yates1, Ms Marie-Claire 0’Shea2

1Queensland University of Technology, Kelvin Grove, Australia, 2Griffith University, Southport, Australia

Background of the project or initiative: Griffith University academics hold expertise in interprofessional simulation-based learning and individual discipline curricula. The Palliative Care Curriculum for Undergraduates (PCC4U) project aims to improve the skill and confidence of health professionals to care for palliative patients. These teams collaborated to redesign elements of a SBLE to develop palliative care and interprofessional capabilities.

The method of research or project implementation: A Collaboration Agreement provided a framework for rights and responsibilities of collaborating partners. The PCC4U palliative care graduate capabilities and interprofessional capabilities informed the review of learning objectives for four discipline cohorts and curriculum mapping. The PCC4U team provided advice on integrating PCC4U resources to strengthen the inclusion of palliative care in the online, pre-simulation learning module and 5.5 hour face-to-face high-fidelity human-patient simulation experience. Post activity, ninety-eight students (39 dietitians, 12 exercise physiologists, 41 pharmacists, and 5 social workers) completed a 44-item PCC4U Palliative Care Graduate Capability Questionnaire.

Project results: Key enablers of this collaboration included early engagement allowing time for planning, review and development activities. Academics’ expertise in individual discipline and interprofessional capabilities enhanced mapping of learning objectives to the palliative care capabilities. The curriculum mapping identified opportunities to improve palliative care learning. PCC4U resources were integrated in a range of formats including eLearning modules, interactive tutorials, lecture and simulation. SBLE feedback was captured though peer review, student survey, critical observers and stakeholder reflection.

Discussion of the outcomes and implications: The PCC4U project supports the inclusion of palliative care through the provision of free learning and teaching resources and partnership opportunities. PCC4U resources provided a valuable foundation in the development and delivery of palliative care education for different health disciplines. Griffith University cross-discipline and sector collaboration has strengthened the review, redevelopment and ongoing refinement of SBLE which will inform delivery in 2019. Further research is required to understand the impact of SBLE on students’ preparation to work with palliative patients in an interdisciplinary context.


Biography:

Kylie Ash is a Registered Nurse with experience in clinical and education roles in oncology and haematology practice settings. Kylie has been involved in a number of large national workforce development projects to improve the intersection of health education and evidence based practice with health policy. Kylie is currently the National Manager for the Palliative Care Curriculum for Undergraduates project (PCC4U). Kylie is actively engaged with professional nursing organisations and is committed to promotion of excellence within the cancer and palliative care workforce.

 

Tables and chairs: An interdisciplinary approach to improving the hospital environment for patients

Dr Adrienne Young1, Dr Peter Thomas2, Ms Prue  McRae3, Ms Mikaela Wheeler4

1Nutrition and Dietetics, Royal Brisbane And Women’s Hospital, Herston, Australia, 2Physiotherapy, Royal Brisbane and Women’s Hospital, Herston, Australia, 3Internal Medicine, Royal Brisbane and Women’s Hospital, Herston, Australia, 4School of Human Movement and Nutrition Sciences, St Lucia, Australia

Physical environment and equipment play a key role in promoting recovery and preventing harm in hospital. For example, having the necessary space and appropriate equipment to sit out in a chair can improve function and meal intake, and prevent pressure injuries. In a tertiary metropolitan hospital in Queensland, Australia, consumer and staff feedback indicated a lack of and/or defective patient tables and chairs at the bedside. In line with the new Comprehensive Care Standard, an integrated and interdisciplinary approach was taken by Physiotherapy and Nutrition and Dietetics to audit the current state of patient chairs and tables, and make recommendations to hospital executive. Two physiotherapists conducted a hospital-wide audit of chairs, noting defects posing potential harm to patients and/or staff (e.g. skin tears, pressure injury, injury from manual handling). A random selection of 59 tables was audited by a dietetic student and the patient themselves. A scale of 1-5 (5 = “great difficulty”) was used by each assessor to rate stability, moveability (wheels, adjusting height up and down), and ease of using the lever. Only twelve patients participated in the audit; others declined due to previously observing/experiencing difficulties moving tables. Of 381 chairs audited, 127 (33%) were deemed to be defective; common defects included torn vinyl (chair base, arm rest) and broken frame. The moveability of tables was problematic for patients (median rating for wheels: 4, adjust up: 5, adjust down: 5) and dietetic student (wheels: 3, adjust up: 3, adjust down: 4); patients also found the lever mechanism difficult to use (median: 4). Defects in basic patient equipment was observed to be common, with significant potential impact on patient care and outcomes. Data from this interdisciplinary audit have been used to secure recurrent budget for equipment maintenance and replacement, and research funding to co-design improvements to patient bedside environment.


Biography:

Dr Adrienne Young is an Accredited Practicing Dietitian, and is currently Principal Research Fellow, Allied Health Professions at the Royal Brisbane and Women’s Hospital. Her PhD research on improving nutritional intake of older medical inpatients has been of interest nationally and internationally, with Adrienne awarded the Health Practitioner Researcher of the Year at the Royal Brisbane and Women’s Hospital research symposium in 2018, and New Researcher Award at the International Congress of Dietetics in 2012. Adrienne has continued to research in the area of malnutrition in older people, with recent work also focused on workforce development to prepare allied health professionals to translate research into their practice.

Supporting a culture of interprofessional awareness and communication – sharing the journey and the learning activities that the Capability Development Team at Capital & Coast DHB has developed to support and increase interprofessional capability in practice

Vicky Ryan1, Melita Macdonald1

1Capital & Coast DHB, Wellington, New Zealand

“The days of the brilliant solo operator in medicine are gone… The ability to be a team player is essential….for the benefit of patients.”

Professor Ron Paterson, NZ Health and Disability Commissioner (2000-2010)

Significantly, patients cite poor or lacking communication as a substantial contributor to dissatisfaction in their care. Like many large healthcare organisations, Capital and Coast District Health Board (CCDHB) is somewhat segmented in its approach to healthcare provision. Professional and organisational barriers can negatively influence communication and therefore patient experience and outcomes.

Creating a sense of team and supporting the development of a diverse workforce is challenging. For the Allied Health, Scientific and Technical workforce, spread across 35 different professions, having a voice and sense of value in such a large organisation is not always the reality. Interprofessional education is recognised as an approach that can improve team work.

The Capability Development Team at CCDHB has taken an innovative and novel approach to supporting a culture change that enables interprofessional practice and improves patient safety and outcomes, as well as communication and a sense of team.

Using an adult learning approach and engaging with key stakeholders, the Capability Development Team has developed several learning experiences that actively promote an interprofessional approach to patient care and a greater understanding of each other’s roles and skills in the patient’s journey. These sessions are part of the new employee’s orientation and support the expectation to work in a collaborative way from the beginning of the onboarding journey.

Recent feedback from participants indicates that these sessions consistently enhance their understanding of and appreciation for the patient journey, other professions and the importance of effective communication and teamwork.

This presentation will share the journey and the learning activities that this team has developed and the plans to further increase interprofessional capability in practice.


Biography:

Melita Macdonald is an Occupational Therapist of 25 years’ experience. She has worked in a variety of clinical settings in New Zealand and in the UK. She was a Team Leader of a multidisciplinary Allied Health Team for 7 years before moving into her current role as a Senior Capability Development Advisor at Capital & Coast DHB (CCDHB) in Wellington, New Zealand in 2017.  The work outlined in this presentation has been achieved in collaboration with, Vicky Ryan, Allied Health, Scientific & Technical Educator, with the support of the wider Capability Development Team at CCDHB.

Vicky Ryan qualified as a Speech-Language Therapist in the UK, and worked in New Zealand for 9 years before moving into her current role as Allied Health, Scientific & Technical Educator at Capital & Coast DHB (CCDHB) in Wellington, New Zealand in 2016.  The work outlined in this presentation has been achieved in collaboration with Melita Macdonald, Senior Capability Development Advisor, with the support of the wider Capability Development Team at CCDHB.

Patients as teachers: Communication skills training for health professionals. Improving the healthcare experience for consumers with communication disability through the development and delivery of an e-learning and face to face training package for health professionals that uses people with communication disability as content experts and educators

Ms Ruth Townsend1, Ms Kathryn  McKinley2, Ms Joanne Sweeney1

1Austin Health, Melbourne, Australia, 2St Vincent’s Hospital Melbourne, Melbourne, Australia

Background: People with communication disability experience barriers to participation in healthcare decision making (O’Halloran, Hickson & Worrall, 2008) and are at increased risk of medical error and poorer health outcomes (O’Halloran at el, 2008; Patak et al, 2009). All healthcare consumers, including those with communication disability, have a right to participate in conversations about their own healthcare.

For the past five years St Vincent’s Hospital and Austin Health have been training health professionals and students to communicate with people with communication disability using an international program from Toronto, Canada (SCAtm). There are currently no known Australian communication skills training programs that have been developed with and are delivered by people with communication disability.

Aims: To improve the healthcare experience for consumers with communication disability through the development and delivery of an e-learning and face to face training package for health professionals that uses people with communication disability as content experts and educators. To improve the skill and confidence of healthcare professionals when communicating with people with communication disability.

Method: Consumers with communication disability were involved in all aspects of the project including steering committee, curriculum development and delivery of training. The project leads coordinated curriculum development and production of videos of healthcare conversations. The package was trialled at each organisation and evaluations completed.

Results: The project remains underway with an expected completion date mid-2019.

Conclusions: An Australian training package, available 24/7, has been developed targeting the communication skills of healthcare professionals. Consumers were partners in designing, building and delivering this training package that empowers busy clinicians working in hospitals to support people with communication disability.

Key words: communication disability; collaboration; healthcare; communication skills training; consumers as teachers, partner conversation training, e-learning

Financial disclosure: This project was supported by a Practice Partner’s Program grant offered by the Health Issues Centre, Victoria.


Biography:

Kathryn Mckinley

Kathryn is a speech pathologist, clinical lecturer and researcher. She is the Speech Pathology Manager at St Vincent’s Hospital Melbourne and a clinical lecturer at the University of Melbourne. Kathryn teaches communication skills to speech pathology students at the UoM and to health professionals. She has undertaken facilitator training locally and in Dublin and Toronto. Kathryn is passionate about communication, health literacy and communication skills training, particularly for patients and residents who may be more vulnerable as a result of their communication difficulties.

Ruth Townsend

Ruth is a speech pathologist and clinical lead across Continuing Care Services at Austin Health, Melbourne. Ruth has extensive experience working in adult rehabilitation including ABI, Stroke, TBI and dual diagnosis (mental health and ABI). Ruth provides communication skills training to speech pathology students at Latrobe University and to health professionals working at Austin Health and the RMTV program (Rehabilitation Medicine Training Victoria). Ruth has completed communication skills facilitator training in Toronto, Canada and is committed to empowering health professionals to learn how to better support people with communication disability.

The case for cross disciplinary reflective practice

Ms Suzanne Dick1

1Harvest Wellbeing, Melbourne, Australia

Suzanne’s consultancy has focused on the training and supervision of staff and creating a climate conducive to organisational growth and innovation. With an emphasis on engagement at all levels of the organisation and an explicit focus on wellbeing as a measure of success, Suzanne works with companies to focus on their people as their most valuable asset, exploring the simple steps organisations can take to improve their overall performance. She has worked therapeutically with individuals with significant mental health and social issues in addition to working with organisations in the areas of policy development, program design and evaluation and improving staff performance.

Suzanne’s strengths include emotional intelligence, integrity, and diligence enabling her to engage effectively with stakeholders and to work both independently and collaboratively in achieving desired outcomes. Her energy is contagious and because of this she is able to work effectively with teams to quickly generate creative solutions to organisational challenges.

Professional supervision is a long-standing tradition which historically focused on more experienced practitioners within a single discipline offering more junior practitioners within the same discipline a safe space for reflection and technical skill development.  This style of supervision typically focuses on quality assurance and administrative elements of the role, in addition to providing support and practice development (Powell, 1993).

A changing regulatory environment and an increasingly multidisciplinary workforce means there is an increased focus on the provision of high-quality supervision, which may or may not be provided by someone from the same discipline.  In cross-disciplinary supervision there is potentially less technical discipline knowledge, with an increased requirement for

the supervisee to identify technical gaps and seek additional expert support as required.  Instead, cross-disciplinary supervision engenders an increased focus on reflection.  Ghaye and Lilyman (as cited in Hewson, 2012) have described reflection as a complex process, ‘a blend of practice with principle‘, and pointed out that ‘the practice of cyclical reflection can quickly become akin to painting by numbers’ (p. 2).

Using case examples and drawing on her experience as a clinician, supervisor and manager, Suzanne seeks to identify the barriers to developing an effective culture of cross disciplinary supervision and embedding a culture of reflective practice.  Suzanne explores key factors in the success of cross-disciplinary supervision, including the benefits of coming together, creating a safe space for reflective practice and explicitly challenging the concepts of hierarchy and competition between disciplines.  By seeking to understand the purpose of reflection other than as a regulatory or an organisational requirement, there is the potential to create a meaningful space which supports professional growth.  Overall opportunities for innovation are identified, and links drawn between a culture of cross-disciplinary reflective practice and the personal wellbeing of those engaged in caring for others.


Biography:

Suzanne is a registered psychologist with extensive experience in health care, forensic and educational systems as a case manager, psychologist, trainer and organisational consultant.

Mealtimes matter: The development of a pilot program for families of children with complex sensory-based feeding problems

Ms Tracy Harb1, Ms Rebecca  Aherne1, Ms Anne  Embry1, Ms Pip  Golley1, Ms Tiffany  Peddle1, Ms Jane  Rogers2, Ms Shien Ee  Tan1

1Canberra Health Services, Women, Youth & Children’s Community Health Programs, Canberra/Belconnen, Australia, 2Child Development Service, Canberra/Holder, Australia

Introduction: Currently, the Child Development Service (CDS) offers assessment, referral and linkages for children aged 6 years and younger, which includes speech and occupational therapy. Children who require intervention are referred to a community-based NDIS partner. There are no dietetic services provided through the CDS. Children requiring dietetic support are often referred to Canberra Health Services without the benefit of an integrated interdisciplinary approach. This may limit the effectiveness of nutrition support for these families, since very often feeding problems result from complex sensory processing problems. The evidenced-based Mealtimes Matter pilot program represents a new service delivery model of care for families and is an interprofessional collaboration between the CDS and the Women, Youth, and Children’s Community Health Program (WYCCHP) Nutrition team.

Objectives: To develop an evidenced-based interprofessional approach to assisting families with complex sensory-based feeding problems.

Methods: A series of meetings and ‘round table’ discussions were held with the aim to improve access to interprofessional services for families of children with complex sensory-based feeding problems. The meetings were attended by dietitians from the WYCCHP and the Canberra Hospital (TCH) nutrition teams and resulted in the development of a gap analysis and project brief outlining options for evidenced-based programs. The evidenced-based Mealtime Matters approach was chosen since it focuses on capacity building and empowering parents to become their child’s ‘therapist’ within a supportive group setting. The WYCCHP nutrition team leader approached the manager at the CDS for occupational therapy input and to scope the potential for collaboration. The project received funding under Allied Health Research Grants and is planned for implementation as a pilot program throughout the 2019 calendar year.

Discussion and Implications: The Mealtime Matters program has the potential to reduce the burden on Canberra Health Services by empowering parents to confidently manage their child’s specific feeding difficulty.


Biography:

Tracy Harb is an Accredited Practising Dietitian specialising in maternal and infant/child nutrition; she currently works part-time for Canberra Health Services, Women, Youth & Children Community Nutrition. Tracy has many years’ experience in clinical practice in both public and private sectors, in addition to many years’ experience in Public Health Nutrition policy and program development for the Commonwealth Government. Tracy has also worked as a Public Health Epidemiologist for NSW Health. She has  completed a PhD at the University of Queensland’s, Faculty of Medicine, Child Health Centre; her research focused on functional gastrointestinal disorders in fully breastfed infants. Her PhD thesis is currently under examination.

Asserting professional value while navigating power relations in the acute setting: a qualitative study of dietitian clinical decision making

Ms Ruth Vo1, Professor Megan Smith1, Dr Narelle  Patton1

1Charles Sturt University, Wagga  Wagga, Australia

Dietitian decision making in the acute setting focuses on identifying and addressing nutritional issues in patients. The aim of this doctoral research was to uncover the nature of clinical decision making of dietitians in the acute setting. A qualitative design within the interpretative paradigm was used, specifically philosophical hermeneutics. Philosophical hermeneutics is concerned with the human experience but more specifically, the interpreted meaning of this experience. This study involved two in-depth semi-structured interviews with ten experienced acute care dietitians that were recorded, transcribed and interpreted using the principles of hermeneutics. A reference group was then used to provide rigour and further interpretation of the findings. Findings revealed the nature of key relationships between dietitians and other health professionals within which the dietitians actively assert the value they believe they can offer to enhance patient care. Power relationships that exist between the dietitian and the medical practitioner, nurse and patient influence the decisions made as well as how dietitians choose to try and implement care plans. Power dominance of the medical practitioner leads to varying degrees of autonomy depending on the dietitians experience, reputation established with individual doctors and nature of the decision. Key responses to power differences in decision making included building and maintaining supportive relationships; advocating to medical practitioners on behalf of the patient; negotiating decisions using a timely, well reasoned and if needed compromising approach; consulting other members of the healthcare team for information or advice; giving instructions to nurses and patients to facilitate patient care with a focus on compliance; and enabling patients by empowering them to be part of clinical decision making about their own nutritional issues. A deeper understanding of this phenomenon provides insight into how decision making occurs and therefore potentially contribute to education, professional development and research activities which subsequently optimise patient care.


Biography:

Ruth Vo is an experienced dietitian who prior to focusing on her PhD full time specialised in gastrointestinal surgical nutrition in the acute setting as well as had formal and informal roles in clinical education. She is finalising a PhD in the nature of clinical decision making of dietitians in the acute care setting. She has designed and facilitated various professional educational events, workshops, seminars in her specialty area as well as lecturing for dietetics programs in NSW.

Interprofessional Family Conferencing (IFC): Translating knowledge to practice using simulation based education

Ms Daniella Pfeiffer1, Mrs Sue Aldrich1

1Health Education And Training Institute, Sydney, Australia

Purpose

Health care professionals across NSW Health have been equipped with knowledge and skills in best practice family conferencing principles through participating in the Health Education and Training Institute (HETI) Interprofessional Family Conferencing (IFC) training program. This program is delivered through a blended learning package including an eLearning module and face to face simulation workshop. The use of simulated patient methodology together with principles of Interprofessional Education (IPE) equips participants with tools and strategies to put their learning into action.

Methodology/data analysis/literature/tools/methods used

Family conferencing is a commonly used interprofessional healthcare intervention that involves the patient, their family and health professionals coming together to communicate around care needs.  Evidence has identified that family conferencing results in increased patient survival, decreased length of stay, decreased readmission rates and higher patient satisfaction. However no formal family conferencing training existed within the NSW Health public health system.

Developed in collaboration with subject matter experts from across NSW Health and incorporating IPE principles in the curriculum content, the IFC program trains health professionals in skills to effectively plan and participate in a family conference. Interactive education and training methods, including simulation scenario based learning encourages participation and promotes strategies for collaborative practice, teamwork and communication. The debriefing phase of the simulation in particular is an effective tool to encourage reflection on performance both individually and as a ‘team’ and carry this learning into ongoing clinical practice.

Discussion/implementation

In 2018, the eLearning module was completed by 411 NSW Health staff and the face-to-face training program was delivered to 200 NSW Health staff via 23 workshops in 13 Local Health Districts and Speciality Health Networks. Evaluations received to date indicate that the program offers valuable learning and that simulation as an interactive teaching and learning tool supports the translation of knowledge into practice.


Biography:

Daniella Pfeiffer and Sue Aldrich are both Senior Program Officer’s at the Health Education and Training Institute

Allied Health Triaging Tool

Dr Sue Fitzpatrick1, Ms Carole  Bowman, Ms Kristi-Lee  Muir, Ms  Kristen  Farrell

1Illawarra Shoalhaven Local Health District, Port kembla, Australia

Prioritising. Triaging. They may be just words but they have different meaning within different health disciplines. In the Illawarra Shoalhaven Local Health District, there was a high degree of variability of clinical priorities and priority tools between allied health professions, with little consultation with stakeholders in the development of these processes. The outcomes of which was confusion and poor understanding from nursing and medical staff about why and when allied health choose to see referred patients.

A common priority tool for allied health was needed to define allied health core business which included the health service clinical priorities and using a consistent priority language. Following an initial consultation with stakeholders – nurses, doctors and allied health, the importance of a common language became apparent. Consultation with stakeholders ensured that the tool performed as a form of communication between medical and nursing staff in regards to priorities and the timeliness of allied health consultation.

A representative group of allied health senior staff co-designed a traffic light system for prioritisation which was designed around Deterioration, Discharge, Wellbeing, and the Impact that allied health intervention would having in the admitted hospital setting. The focus on the impact of allied health intervention was in 4 possible ways: significant impact, considerable impact, some impact and unlikely impact, allied health professionals are able to externalise their often internal prioritisation processing and explain these to each other and other stakeholders. The focus on Deterioration, Discharge and Wellbeing resulted from consultation with nursing, medical and allied health professionals in response to the question, “who would allied health prioritise if they were unable to see all patients referred in a given week?”

This presentation details the process of co-design and the pre and post evaluation of the tool in changing health professionals understanding of prioritising incoming referrals as well as defining the core business of allied health. The tool is a great example of co-design across health professions and the need for overarching agreed principles for understanding who we see first, when and why.


Biography:

Sue Fitzpatrick has abackground in speech pathology and was awarded a doctor of health science in 2016 on teh topic of clinical supervision in allied health. Sue has an interest in alleid health leadership and empowering up and coming allied helath leaders.

Kristi-Lee Muir is a senior physiotherapist who has a range of clinical experience. Kristi-Lee brings this experience to allied health projects and has an interest in collaborative leadereship and working in an interdicsciplinary way across allied health to acheive great client outcomes.

Health professionals’ understanding of interprofessional education and collaborative practice: A Queensland survey

Dr Priya Martin1, Dr Alison Pighills2, Ms Lynne Sinclair3

1Cunningham Centre, Darling Downs Health, Toowoomba, Australia, 2Mackay Instutute of Research and Innovation, Mackay Hospital and Health Service, Mackay, Australia, 3Centre for Interprofessional Education, University of Toronto, Toronto, Canada

Background: There is an increasing awareness of the importance of interprofessional education and collaborative practice (IPECP) in improving health outcomes for patients and organisations. Whilst university education for health professional students is focusing more on IPECP, recent literature has highlighted gaps in interprofessional practice learning experiences, understanding and skills in healthcare settings. This survey study aimed to investigate health professionals’ understanding of IPECP, as well as measure their readiness to facilitate interprofessional education (IPE) in clinical settings.

Method: All allied health professionals, nurses and doctors in two regional health services in Queensland were invited to complete an online, anonymous Survey MonkeyTM survey. The survey is currently open and consists of 24 questions.

Results: 94 respondents have so far completed the survey representing seven allied health professions, medicine and nursing. Preliminary analysis of available data indicates the following: 49% of respondents have been in the current role for more than 10 years; over 70% are in a clinical role; 80% of the respondents are not aware of different IPE terminologies; just over 40% can explain what IPE is to a colleague; 74% agree that IPECP leads to improved patient outcomes; only 36% understand the difference between multi-disciplinary, interdisciplinary and transdisciplinary teams; 39% of respondents are confident in facilitating IPE of students from their own profession and only 23% are confident to facilitate IPE for other professions; only 7% are aware of IPE frameworks; 22% are aware of IPE resources and just over 10% have completed IPE training. The final survey results will be available and presented at the conference.

Discussion: This study has revealed the areas for improvement to enhance IPECP in two Queensland regional health services. This information will be used in developing targeted interventions including state-wide training. Study findings will be of interest to similar healthcare settings internationally.

Acknowledgement – Toowoomba Hospital Foundation Research Grant


Biography:

Alison completed her PhD in 2008 at the University of York, UK, which involved a RCT (n=238), to evaluate the clinical effectiveness of environmental assessment and modification to prevent falls in older people. She was awarded the University of York K M Stott prize for the best PhD thesis. She is currently a co-investigator on a multi-centre RCT in the UK (n=1333) which replicates her PhD research on a larger scale. Her research interests include: falls prevention, rural and remote models of care, professional skill sharing and delegation; and, research capacity development.

NAHC Conferences

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2009, Canberra (8th NAHC)

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2013, Brisbane (10th NAHC)

2015, Melbourne (11th NAHC)

2017, Sydney (12th NAHC)

2019, Brisbane (13th NAHC)

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