Built on We Are: How Dorothy Bouldrick is creating behavior-changing training in healthcare

Before she starts designing any type of training, Dorothy Bouldrick, DHA, MBA always asks herself one important question:

“What are the critical behaviors the learner is not doing well?”

Everything for her starts there. If that behavior doesn’t change, the training isn't working.

With more than 25 years of experience in health and education, Dorothy has been designing evidence-based learning experiences that build capability, change behavior, and support measurable performance outcomes.

“What I really love is when the evidence shows the learning experience I created actually had an impact in the workplace. That's essential.”

That is why, when she looks into building on any learning design tool, she is always in search of one that can act as a delivery mechanism for the curriculum to support the learning objectives.

A learning design tool for practice-based training

One of the most difficult skills to develop in healthcare, Dorothy explains, is delivering difficult news to patients and their families.

"It's one of the most challenging things clinicians have to do," she says. "And they don't have a lot of opportunity for deliberate practice. Often, they're experiencing it for the first time in the flow of work."

Dorothy wanted to change that. Her plan was to build simulation-and scenario-based training grounded in the evidence-based frameworks clinicians actually use. Giving them a safe space to practice these conversations before facing real patient or their families.

She was already using an avatar tool for coaching, but she still needed somewhere for the scenario itself to live. That's when she came across We Are Learning.

"We Are is essential because that's where the deliberate practice takes place. It is great for creating these realistic scenarios. They give clinicians the opportunity to practice those skills, so they can feel competent in having these difficult conversations without losing the flow of their professionalism, while being empathetic.”

And in healthcare, to ensure that training is actually helping learners change their behavior, every response a learner chooses needs to be measured against the frameworks clinicians actually use in the field.

Applying evidence-based frameworks such as SPIKES and NURSE

Dorothy’s simulation is grounded in SPIKES and NURSE.

For quick context:

SPIKES is a widely used six-step protocol for delivering bad news in medicine: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary.

NURSE is its companion for expressing empathy (Naming, Understanding, Respecting, Supporting, Exploring).

She uses both of these frameworks within We Are so they can become something learners actually use. She says,

“What I love about We Are is that I'm able to enter critical behaviors into the skills. As learners select what to say to the patient or family, I can provide them with an assessment. As learners select what they would say to the patient or the family, they get immediate feedback. They know whether they selected the right response based on the SPIKES or NURSE framework.”

This way, within We Are, Dorothy was able to set the scene as closely as possible to a realistic environment. This also meant that the learner would be responsible for selecting the conference room or the office where they would have the conversation. They need to know what the setting would be, and with the 3D characters, she was able to convey a wide range of emotions through gestures that could be incorporated into the conversation.

“So that learners will be able to see, hear, and experience the emotional part of it. This is where it gets more immersive.”

Immersive doesn’t always need a headset

Dorothy needed something that felt real; however, for her, it didn’t require expensive technology or gear.

“For me, on an enterprise level, immersive means to be able to create an environment that matches or is very similar to your real-world environment. And you don't need a headset to do that.”

She emphasizes that for training to be really immersive, you need ‘a very good script that’s grounded in real-world context, and a great tool that lets you present emotions in the simulation.’

Her scenario was written from a real patient experience. The learner plays the role of a clinician who must tell a patient, Sarah, that her cancer treatment is not working, while Sarah recounts how her early concerns were dismissed, and her husband asks what they're supposed to tell their two little girls.

"When the learner is engaging with this scenario, they're able to feel and have an emotional response based on the character's emotional response," Dorothy explains. "The 3D characters have so many emotional gestures. The learner can see, hear, and experience its emotional aspect. It doesn't sound robotic — it's very real.”

The practicality matters too. Her learners learn in the flow of work, such as sometimes on a lunch break.

"If I've got a 15-minute break and I know I have a patient I'll have to deliver bad news to at 2:00, I don't have to find a headset. I can log on, get some practice in…maybe get rid of some of my nerves before I have to do it in a real-world setting."

A safe place to make mistakes

For Dorothy, immersive learning is a psychologically safe space.

“You can practice, you can make mistakes, and you can correct them right there in the immersive environment. So when you actually have to do this with a live patient, you've already assessed: this is not the best response."

That balance is needed. Dorothy explained that simulations can be too real, sometimes invoking the uncanny valley— an experience, a psychological phenomenon where a humanoid object—like an AI avatar, robot, or CGI character—looks almost perfectly human, but slight imperfections trigger a sense of unease, discomfort, or revulsion in real humans.

We Are Learning avoids the uncanny valley trap altogether by using a friendly, Pixar-style 3D aesthetic—an obviously fictional yet highly expressive look that feels natural to viewers. This helps to create a psychologically safe environment for learners to engage in deliberate practice and provides a positive impact on learners.

"I never have my patients die during a simulation," she says. "It's realistic enough for learners to feel the consequences of their choices, but it's not detrimental to their psyche if they don't get it right the first time."

Did the behavior change?

For Dorothy, the story ends with evidence. Her simulation is wrapped in pre- and post-tests, and the real litmus test comes later, in the workplace: has this skill actually changed any behavior?

"That's the data that lets me know what I'm doing is effective. If there has been a change in the behavior, that means I selected the right tool. Selecting the right tool is just as important as having the correct content."

And she's just getting started. Beyond the conference demo, she's already planning new scenarios, including conflict-resolution training for healthcare leaders facing high-pressure situations.

"I'm just getting started, and I'm already in love with it. There are so many learning designs I want to build here."

Built on We Are is a series that spotlights the people using We Are Learning in creative, unexpected ways and the thinking behind what they build.