Embracing Avatars

"Who is Dr. Chen?” Columbia Nursing student Kerrick Dougherty wondered to himself when he opened an email introducing the “professor” who would be working with him on a pre-simulation assignment in the Masters Direct Entry (MDE) program. “I thought I knew all of the MDE faculty at Columbia Nursing,” he remembers thinking. Then he clicked on the link and saw an artificial intelligence (AI)-powered avatar smiling at him. 

At age 30, Dougherty is no stranger to AI platforms like ChatGPT. Still, he felt hesitant about engaging with a virtual nurse-professor. “I was a little nervous,” he says. “Being face-to-face with patients was the reason I got into nursing. I didn’t want to dehumanize my profession.” Yet as the avatar guided him through the material, asking questions and providing real-time, compassionate feedback, his comfort with the process grew. “Dr. Chen is definitely a good launching pad for learning,” Dougherty says.

Educational innovation has long made Columbia Nursing one of the most renowned schools of nursing in the country. Now, the institution is bringing learning to the next level with human-like, interactive nurse avatars that engage students in one-on-one conversations to help prepare them for assignments and clinical experiences that they’ll encounter in the simulation center, explains Natalya Pasklinsky, DNP, an associate professor and the assistant dean of the Helene Fuld Health Trust Simulation Center. “We are one of the few schools nationwide beginning to use AI in this new way, embedding it into education,” she says. In addition to helping students complete written assignments, the avatar quizzes them orally on clinical topics, such as disease presentations and how to know whether certain interventions are working, pushing them to think critically and on their feet—skills that are essential to delivering superior nursing care. “In using avatars, we are not looking for correct answers but the frame of thought that reveals students’ understanding, interpretation, or lack of knowledge,” Pasklinsky says. “We want to get down to the root of students’ thinking, not just what went through their mind but the thoughts behind their actions.” 

Expertly programmed

Simulation Technology Manager Juan Gonzalez is the talent behind Dr. Chen, Dr. Pedro Bennett, and other avatars that he has developed to represent professors, patients, and even pediatric patients’ parents for MDE students. Creating these avatars, some of whom he modeled after actual faculty members, entailed working closely with content expert Kristy Deyeso, DNP, who provided Gonzalez with all the subject material in the pre-simulation course, such as techniques for inserting a Foley catheter, changing a central line dressing, managing a chest tube, and recognizing signs of a stroke.

During students’ ob-gyn rotation, for example, avatars cover clinical issues like recognizing and treating preeclampsia, as well as social determinants of health like assessing how nutritiously a pregnant woman is eating; ensuring that she doesn’t miss her prenatal care appointments; and supporting her during labor, delivery, and the postpartum period. During their pediatric rotation, avatars teach students how to assess patients with abdominal pain for appendicitis, recognize signs and symptoms of an asthma attack, and treat a child who is seizing or going into anaphylaxis. “We want students to be prepared when they get into the sim lab to put into hands-on practice what the avatar has taught them,” Deyeso says.

To ensure that avatars dispense only accurate information, Gonzalez creates “guardrails” around specific topics by adding relevant policies from health agencies like the Centers for Disease Control and Prevention. “I receive all the information from Kristy and do a little of my own research,” he says. “When I see the avatar can have a fluid conversation, allowing me to speak with it and ask questions, then I send it to the instructor and make sure it performs properly.”

For the pre-simulation assignment, Gonzalez programmed Dr. Chen to conduct a pre-brief, an explanation of the assignment’s content and focus; a question-and-answer period, designed to reinforce students’ knowledge by quizzing them on the simulation-related material they should have studied (asking, for example, “What’s the first thing you do when you step into a patient’s room?”); and a debrief, during which Dr. Chen or another nurse avatar engages students in a reflective discussion about their performance, clinical reasoning, and communication during the simulation. “The nurse avatar provides personalized feedback, reinforces key learning objectives, and encourages critical thinking to improve future clinical practice,” Gonzalez says. Following the debrief, students write a 300- to 500-word reflection paper, analyzing their performance, identifying what they have learned, as well as their strengths and areas for improvement, and connecting their experience—along with two of their biggest takeaways—to real-world clinical practice. “This written assignment promotes self-awareness and deeper learning and must be submitted to Canvas for instructor review,” Gonzalez says.

Human-like responses

One of the features that makes the avatars so human-like is their ability to respond in the moment. “These avatars adapt in real time, responding differently based on what you ask,” Pasklinsky says. If a student omits steps in inserting a Foley catheter, for example, the avatar will offer a gentle reminder to get them back on track. As one student wrote, “One thing I took away from the simulation was the correct order of donning and doffing PPE [personal protective equipment]. [Dr.] Chen helped to clarify the importance of each step and explained that improper use of PPE can lead to contamination.”

Another human-like feature of the avatars is their ability to respond to different tones of voice. They can detect if students are rushing, aggressive, unsure of themselves, or off topic. For example, another student wrote that “the avatar actually listened to my questions and responded in ways that reflected my tone and wording. It felt like a genuine conversation, which made the experience both engaging and educational.” 

Such real-time, back and forth interaction fosters learning more effectively and immediately than rote writing exercises that students may not receive feedback on for several days. Moreover, since the avatars are generative, they learn and evolve with every use. “The more you interact, the more they grow and learn to answer differently, so no two students have the same experience,” Gonzalez says. 

No Nerves

MDE student Jennifer Skor is not a shy person. But when it comes to asking questions in group settings, she gets nervous. “I get intimidated, even with standardized patients,” Skor admits, referring to the professional actors Columbia occasionally hires to role-play patient-provider interactions with students.

But, with avatars, Skor says, “There were no nerves.” She attributes this in part to the avatars’ 24/7 availability, which allowed her to work with them in the privacy of her home, whenever and as frequently as she liked. “There was no time limit, and there were no other students around, so I didn’t feel judged,” says the 50-year-old mother of two. “I like to ask a lot of questions to make sure I really understand material, and with an avatar I could ask as many questions as I wanted and not feel like I was talking over my classmates.” The avatars’ one-on-one mentorship created a space that felt safer than a classroom, preparing her better for the simulation lab than participating among peers, she says.

Dougherty sometimes feels intimidated when asking questions in class, too. Overlooking some of the steps in preventing a central line infection made him especially self-conscious. To his surprise, Chen commended the knowledge he did display and in a kindly way named the steps he omitted. “It was nice to have a friendly reminder in a nonjudgmental environment,” Dougherty says. “No matter my level of experience, Dr. Chen provided a safe place to land.” 

Supportive and Inspiring

In partnership with Deyeso, Gonzalez programmed the avatars to be mentors who are compassionate and encouraging, giving students the freedom they need to make mistakes. “We didn’t want students to walk away feeling like they were being scolded, we wanted to create a safe space for them to learn and engage,” Deyeso says. 

Indeed, the patience, encouragement, and compassion that the avatars extended made Dougherty feel safe. In addition to encyclopedic capacity for clinical knowledge and real-time responsiveness, they are equipped with voice activation technology that enables them to detect a student’s hesitation when answering a question. In response to an uncertain tone, an avatar may say, “I noticed you were hesitant” or “I noticed you took longer to respond to that question,” and then invite the student to request help understanding the material.

Having chosen nursing as a career change, Dougherty needed a good deal of help with most of the information he encountered. “Whenever Dr. Chen asked a question that I couldn’t answer, she created a safe space for me to work through my uncertainty,” he says. “This reminded me that asking a question is far better than pretending to know something out of fear of being perceived as incompetent. After all, one question can save a life!”

Notes Deyeso, “One of the things I really like about the avatars is that if a student gets something wrong, they keep teaching in a compassionate way, so the student wants to keep going.”

Such supportiveness helped Dougherty gain comfort with unfamiliar scenarios while strengthening his mastery of the content he was learning. “Dr. Chen’s feedback reassured me that I was truly retaining material, which has been both inspiring and motivating in my learning journey,” he says. “Whether I entered a simulation with Dr. Chen well-prepared on the topic or uncertain, I have found that another perspective always contributes to well-rounded care.”

Prepping for real encounters

The wide array of avatars that Gonzalez has created allows students to practice communicating with the many people, including patients and parents, whom they’ll encounter in various health care settings. “Every student has a different experience, which is important because every patient they meet is going to be different,” says Assistant Professor Kathleen Mullen, DNP. “As a nurse, you have to adapt to every situation.” In this way, she adds, “the avatar gives students a much more rounded education that’s not rote and stuck in the same pattern.”

For example, the avatars enable students to practice explaining to patients why they’re in the hospital or why their child needs surgery. They also ready them for one of the most difficult aspects of nursing—breaking bad news to a patient’s family. “Therapeutic communication is a skill that all nurses have to develop,” Mullen says. “Avatars provide feedback about the nuances of conversation between nurses and patients that students can use to understand when they’re coming across well and where they have to make changes.” As one student reflected, “This simulation reminded me that effective communication isn’t something that happens automatically. It’s a skill that requires intentional effort, practice, and feedback.”

For Skor, working with the avatars also helped her learn “nursing lingo,” which she found to be especially important in giving reports. “They helped me switch from speaking in lay terms to using the correct clinical language,” she says.

Avatars can even prepare students who want to enter nursing administration for the challenging conversations that they will likely have when proposing programmatic changes, says Mullen, who teaches a course about quality improvement in the school’s Masters in Advanced Clinical Management and Leadership program. Geared toward nurses aspiring to advance from middle to higher management, the course requires students to develop a quality improvement project. For one project, Mullen asked Gonzalez to create an avatar in the form of a correctional facility administrator who opposed a prison-wide flu vaccination program. Students assumed the role of public health nurses who had to persuade the administrator of the program’s importance. “The administrator, who was very resistant to change, was not at all interested in the program,” Mullen says.

Meeting such resistance is exactly the type of experience students need as they prepare for a career that involves implementing change to improve quality, Mullen explains. “Whenever you propose or institute change, there are going to be people who question or say they don’t like it,” she says. “You have to communicate and work with people to get change accepted, despite the barriers.” Furthermore, she adds, “the avatar evaluated students’ responses to the administrator and let them know if they came across as objective, and if there were opportunities where they could have pushed a little harder or achieved more in conversation.” 

Pasklinsky found the prison administrator to be so realistic, she almost forgot that she was interacting with an avatar. “I really felt like I had a stake in his allowing me to vaccinate inmates. As the case went on, I felt more empowered and thought, ‘I’m going to convince this guy.’ As an experienced practitioner, I was sweating,” she says. 

Engaging a younger generation

Years ago, assignments in the MDE program consisted largely of writing answers to questions. Back then, search engines and AI platforms like ChatGPT made it possible for students to quickly search for, copy, and paste their answers, Deyeso says. Avatars eliminate such shortcuts. “Now students have to have a conversation out loud,” she says. The process reinforces their learning and assures professors that they are absorbing the material. “With an avatar, I know students are talking through scenarios because they are coming better prepared to simulation sessions,” observes Deyeso.

Not surprisingly, avatars resonate especially well with younger students, who came of age playing video games or enjoying other high-tech visual experiences that make didactic learning dreary by comparison. “When you’re looking at a static picture, you’re not as engaged as when you’re looking at something dynamic and moving,” Mullen says. The avatar draws students in and makes them feel like the work they’re doing is not just another routine assignment. “It engages students in a way they’re used to engaging, moving and talking, while giving them the kind of feedback about their communication that helps them learn going forward,” she says.

A work in progress

But as advanced as they are, Columbia’s avatars still need some smoothing out, faculty and students agree. For instance, they’re highly sensitive to background noise, so they can easily mistake audio from a television or radio for a student’s voice. Dougherty observed a related shortcoming. “If I paused,” he says, “the avatar would think I was finished speaking when I wasn’t and move on to the next thing.” Skor learned to sidestep glitches of this kind, which occurred when her husband was watching TV, by typing her questions and awaiting the avatar’s spoken response.

“We’re still in the baby stages,” Pasklinsky says. “This technology will grow in leaps and bounds and exceed everything we’ve expected.” That said, she cautions students against relying on avatars for all their learning. “This is not to say you should 100% rely on avatars, but they do help the human mind explore different ways of thinking,” she says.

Indeed, it is with some relief that students notice avatars’ limitations. “Avatars are never going to replace our professors,” Skor says. “They’re a good pre-learning activity, but you need in-person instruction to learn physical skills. For that reason, avatars will never replace human beings. They’re just a good supplementation.” 

Photographs by Jörg Meyer

This article originally appeared in the Fall/Winter 2025 issue of Columbia Nursing Magazine.