KT Waxman, DNP, MBA, RN, CNL, CENP educates and informs the community about the alliance.

The California Simulation Alliance (CSA), established in 2008, led by the California Institute for Nursing & Health Care (CINHC) in Oakland, California, is a virtual alliance to benefit all simulation users in the state of California. The mission of the CSA is to coordinate and expand the use of all forms of simulation in academic and service settings across the state to advance healthcare education ultimately resulting in enhanced patient safety for Californians. The CSA is governed by an inter-professional advisory committee and a steering committee comprised of representatives from all seven regions comprised of schools of nursing, allied health, medicine and hospitals.

The CSA evolved from initial work in the San Francisco Bay Area with the Bay Area Simulation Collaborative (BASC) in 2006. The CINHC, the state’s nursing workforce center, received a grant from the Gordon and Betty Moore Foundation for the CINHC to create the first formal, urban simulation collaborative in the US. The BASC comprised more than 100 schools of nursing and hospitals, totaling more than 600 faculty and hospital educators from around the Bay Area in 10 counties around the San Francisco Bay. This 3-year funded project was designed to train and educate healthcare faculty in the concepts of simulation (Waxman, et al, 2011).1 Th three objectives for the project included a faculty development plan, scenario development and a research agenda. The BASC is still operating as a regional collaborative under local leadership and is one of the seven regional simulation collaboratives in California.

The purpose of the CSA is to become a cohesive voice for simulation in nursing education across the state, to disseminate information to stakeholders, and to establish a universal entity for simulation. (Photo: KT Waxman, DNP)
The purpose of the CSA is to become a cohesive voice for simulation in nursing education across the state, to disseminate information to stakeholders, and to establish a universal entity for simulation. (Photo: KT Waxman, DNP)


Leveraging the initial investment for BASC, the CSA was formed. The purpose of this alliance is to become a cohesive voice for simulation in nursing education across the state, to disseminate information to stakeholders, and to establish a universal entity for simulation. In addition, the aims of the alliance include providing a home within the CINHC for best practice identification, information sharing, faculty development, equipment/vendor pricing agreements, space planning, scenario development, sharing and partnership models, and inter organizational research via a statewide research committee.

Regional Collaboratives

Seven regional collaboratives have emerged within California over the past six years: the Rural Northern Area Simulation Collaborative (RNASC) serving the North, housed in Chico; the Capital Area Simulation Collaborative in the Sacramento region; the BASC serving the San Francisco Bay Area; the Central Valley Simulation Collaborative (CVSC), serving the Central Valley from Bakersfield to Modesto; the SCSC, serving the Los Angeles/Orange County region; the Inland Empire Simulation Collaborative (IESC), and the San Diego Simulation Collaborative (SDSC). Over the next few years, it is anticipated that several more collaboratives may emerge especially in the Southern California area. Of the seven collaboratives, a few were funded, while others are grassroots groups. The SDSC in San Diego received start-up grant funds from the Education Department at the state capital, the RNASC received a rural grant and the SCSC is mentioned below. (Figure 1).

Through the initial investment and with the success of the BASC, another funder, Southern California Kaiser Permanente Community Benefits Program, funded the CINHC to lead a project in the Los Angeles region to replicate the work of the BASC. The 3-year grant called for the development of a Southern California Simulation Collaborative (SCSC), an academic/service operating committee, training for faculty, a site assessment of potential regional centers, and scenario development. After completing this 3-year project, more than 200 educators have been trained, a train-the-trainer program was implemented, the operating committee has met every other month, the site assessment is complete, and scenarios have been written. The SCSC is now one of the seven regional collaboratives in the state.

  • Other collaboratives around the state have been growing from grassroots efforts. The Central Valley Simulation collaborative (CVSC) is an example of one of the regions that, even though they have no funding, have managed to meet regularly, hold classes for its constituents and work together to integrate simulation into both schools and hospitals in the central valley of California. Committees Four committees are in place within the CSA: Research: This committee is comprised of multiple simulation stakeholders in the state. They track research activities in the state in schools and hospitals and were instrumental in conducting our statewide simulation survey over the past five years;
  • Scenario writing: This committee was instrumental in standardizing the CSA scenario template, which was modeled after the BASC template. They continue to hold scenario writing groups to contribute to the 75 scenarios on the CSA website;
  • Technology: This committee is comprised of simulation technicians and simulation faculty that assist with our website development, simulation technician training and overall simulation needs on the technical side. They also remind us that simulation isn’t all mannequin based; and
  • Scholarly writing: This committee led the effort to create a bibliography of current simulation articles for our subscribers. Additionally, they completed an inventory of CSA member writers and track this data.

Faculty development


Leveraging the successful BASC faculty development program, the CSA adopted the program to roll out statewide. In 2006, a comprehensive faculty development plan was designed by the BASC operating committee and program director. The goal was to train a large number of expert clinicians and nursing faculty in the Bay Area, and the plan was built on the novice-to-expert model. In this plan, the faculty member (learner) in Level 1 training (basic technical skills) is in the novice stage, Level 2 (simulation methodology) is the advanced beginner stage, Level 3 (apprenticeship) is the competence stage, and Level 4 (train the trainer) is the proficient and expert stage. Ultimately, a train-the-trainer model allowed the BASC to have its own qualified instructors to teach others. 2

The CSA added an apprentice program in 2010 as it was successful in the Bay Area. This apprentice program is a 72 hour comprehensive training program where faculty can hone their skills with experts in the field. (This curriculum was purchased from SimHealth Consultants in Oregon). Four CSA sanctioned apprentice sites have been named: Samuel Merritt University in Oakland; the Center for Advanced Pediatric and Peri-natal Education (CAPE) at Stanford; and Little Company of Mary Medical Center in Torrance. Once faculty complete the apprentice program, many go on to become CSA faculty.

The train-the-trainer program was implemented statewide and currently there are qualified CSA faculty in each of the seven regions to perform training in their specific area. Over 2,000 faculty from nursing schools, pharmacy schools, paramedics, medicine and technicians have been trained since 2008 through the BASC/CSA educational programs.


The governance of the CSA includes representation on the steering committee from both schools and hospitals across the entire state. The CSA has been developed through the facilitated efforts of a group representing nursing education, nursing practice, professional organizations, allied healthcare disciplines, and the state licensing board for registered nurses, so that the best thinking can be tapped from leaders of key constituencies used to build consensus. The future for CSA is to become the voice for simulation in Sacramento and facilitate state funding for simulation use and expansion.1.


Since no grant funding is currently available for the CSA, the organization has been sustainable due to their four revenue sources: subscription fees, course revenue, apprentice fees and industry partners/sponsors. Subscription fees were implemented in 2011 for individuals and institutions. The CSA has 75 scenarios available on their website (www.californiasimulationalliance.org) and are available for download for all subscribers. These scenarios were written, validated and tested by CSA and BASC members and many of them have been updated to include QSEN competencies.

With our partnership with the Victorian Simulation Alliance (VSA) in Melbourne Australia, we plan to sell the CSA/VSA programmed scenarios is on the agenda for the end of this year. Courses are discounted for subscribers and any excess of revenues go back to the CSA for sustainability. The apprentice program also provides revenues and lastly, sponsorships and pricing agreements from industry partners help as well.


The Victorian Simulation Alliance (VSA) was modeled after the CSA. This alliance has been in place for three years and is growing in their state. They have become a model in Australia for other states to develop their own regional or statewide alliance. Plans for the VSA and CSA to participate in joint educational sessions and scenario development are occurring this year. Together the VSA and CSA have launched the Trans-Pacific Simulation Alliance and will develop strategy around this alliance in 2014.

Clinical placements

The current California Board of Registered Nursing regulation allows schools of nursing to utilize 25% of clinical hours per course in simulation. The CSA has performed a statewide simulation survey recently that revealed many schools are only using 15% and there is still opportunity to increase by 10%. With clinical placements being more difficult to secure, simulation labs are being used as clinical sites where students can be guaranteed a clinical experience. For this reason, the CSA hopes to standardize the way we teach in simulation, clearly define what simulation is (not an expensive skills lab) and monitor the use in California’s schools.


The CSA has created an infrastructure for integrating all types of simulation into the curricula of California schools of nursing, allied health and hospitals and has made possible a consistent, standardized methodology for the use of simulation. Consistency in the education of faculty, students, and healthcare professionals through simulation will help improve patient safety and healthcare delivery in California.

Integration into both school and hospital curricula is critical to the success of a simulation program. The alliance shares best practice models for successful curriculum integration, holds workshops on this process and, additionally, helps hospitals with integrating simulation into their patient safety programs to meet the national patient safety goals. Through collaborative relationships with hospitals, health systems, and schools of nursing committed to incorporating simulation into their education and training programs, the CINHC successfully supports the CSA and its sustainability.

Moving forward, the CSA goals for 2014 include establishing more industry partnerships, hosting a 1-day simulation conference, and continuing to refine and offer simulation courses to subscribers and non-subscribers. These courses will include creating a business plan for simulation lab sustainability, preparing for certification and accreditation, specialty courses such as OB crisis and more. We hope to increase our number of subscribers, and creating videos for subscribers to view simulations as an educational tool.

About the Author

KT Waxman, PhD, is a nurse leader with over 30 years of experience in health care and corporate settings. She is a tenure-earning Assistant Professor at the University of San Francisco School of Nursing and Health Professions and Chair of the Doctor of Nursing Practice (DNP) Department. She is co-director of USF’s Masters of Healthcare Simulation program, launching in Summer, 2014. As the Director of the Department of Defense grant funded simulation research study, she completed the study on medication error recognition and simulation modalities. The research paper is in press.

Dr. Waxman is also Director of the California Simulation Alliance (CSA) at the California Institute for Nursing & Health Care. An internationally known speaker and author, Waxman is past president of the Association of California Nurse Leaders and currently serves as Treasurer of the American Organization of Nurse Executives , a 9,000-member association. She served as Co-chair of the International Meeting on Simulation in Healthcare for the Society for Simulation in Healthcare in 2012.

Dr. Waxman’s work has been published extensively and can be found in journals such as; Simulation in Healthcare, Clinical Simulation for Nursing, Journal of Nursing Education, Nurse Leader and Creative Nursing, and is a chapter author for 3 simulation textbooks. She also authored the book “A Practical Guide to Finance and Budgeting: Skills for Nurse Managers”, now in its second edition. Her second book “Financial and Business Management for the Doctor of Nursing Practice” was released in November 2012. Waxman received her DNP from the University of San Francisco, with an emphasis on health systems leadership and a concentration in clinical simulation. She holds national certification as a Clinical Nurse Leader and as a Nurse Executive.


1 Waxman, KT, Nichols, A., O’Leary-Kelley, C., & Miller, M. (2011). The Evolution of a Statewide Alliance: The Bay Area Simulation Collaborative. Journal for the Society for Simulation in Healthcare.

2Waxman, KT, & Telles, C. (2009, November). The use of Benner’s framework in high-fidelity simulation faculty development: The Bay Area Simulation Collaborative model. Clinical Simulation in Nursing, vol (5).