Pain and Palliative Care

NIH Healing Experience in All Life Stressors (HEALS)

About NIH HEALS

Healing Experience in All Life Stressors (HEALS) was created by the NIH Clinical Center Pain and Palliative Care Service as a psycho-social-spiritual measure of healing that assesses positive transformation in response to challenging life events. It is a self-report, 42 item questionnaire.

HEALS was developed by the observation that some patients with life-threatening or chronic illness report positive psychological, social, and spiritual change during the diagnosis or treatment of their illness, even in the face of unfavorable prognosis.

Identifying the factors that contribute to or detract from the positive transformation known as "healing", has far reaching implications for interventions aimed at improving quality of life, mind, body, and spiritual wellness in the face of life's challenges.

For More Information

Use of HEALS is free. For registration and permission to use HEALS or for further information, contact:
Ann Berger, MSN, MD
aberger@cc.nih.gov

Background

There are an abundance of measures in the literature that assess quality of life with questions relating to functionality, symptoms, and psychological, social, and spiritual issues. However, a focused and comprehensive review of the literature pointed to an important gap – a comprehensive measure of healing to assess this important facet of human experience, even in the face of great adversity, was lacking.

The initial concept of HEALS was derived from two sources:

  1. Observations by the NIH palliative care providers who cared for patients with terminal and serious illness that often led to death
  2. An in-depth review of the literature to conceptualize, define, and identify underlying constructs related to healing.

Our initial studies were qualitative and conducted with cardiac and cancer patients who reported positive life transformations. The themes that emerged from interviewing patients included:

  • relationship with a divine entity
  • nature
  • self-introspection and mindfulness
  • awareness of mortality
  • stressors
  • depth of relationship with family, friends, and other people.

The patient interviews and the integration of the literature guided the selection of HEALS items. We then conducted two studies to validate and refine the HEALS:

  • a factor analysis study
  • a cognitive interviewing study

These two studies, the factor analysis and the cognitive interviewing, assisted in refining the HEAL's questions and to also reduce the items from 54 to 42.

The factorial structure of the tool was studied with 100 patients. Following that factor analysis, cognitive interviewing processes were used with a separate group of 36 patients. The examination of the factorial structure revealed four factors:

  1. Religion
  2. Spirituality
  3. Intrapersonal relationships
  4. Interpersonal relationships

Cognitive interviewing is a highly recommended technique to improve the validity and relatability of questions in surveys and questionnaires. In this process, the respondents are interviewed to better understand their comprehension of the questions and the cognitive processes underlying their response to these questions. This is also to ensure that the respondents comprehend and interpret the questions in the way in which the question was intended.

Further validation studies are currently in progress.

Recent Publications

Coats, H., Rosenfeld, A., Crist, J., Sternberg, E., & Berger, A. (submitted). Using cognitive interviews to improve a Psychological-Social-Spiritual Healing Instrument: Voices of Aging African Americans with Serious Illness.

Sloan D H, BrintzenhofeSzoc K, Kichline T, Baker K, Pinzon J P, Tafe C, Li L, Cheng M J, Berger A. (2017). An assessment of meaning in life threatening illness: development of the Healing Experience in All Life Stressors (HEALS), Patient Related Outcome Measures, 8: 15–21.

Young W C, Nadarajah S R, Berger A. (2016). Supportive medical care in life-threatening illness: A pilot study, Palliative and Supportive Care, 1-6.

Young W C, Nadarajah S R, Skeath P R, Berger A. (2015). Spirituality in the context of life-threatening illness and life-transforming change, Palliative and Supportive Care, 13(3):653-60

Coats, H., Crist, J., Berger, A., Sternberg, E., & Rosenfeld, A. (2015). African American elders' serious illness experiences: Narratives of "God did," "God will," and "Life is better." Qualitative Health Research. Doi: 10.1177/1049732315620153. PMID: 26701962.

Holder G N, Young W C, Nadarajah S R, Berger A. (2014). Psychosocial experiences in the context of life-threatening illness: The cardiac rehabilitation patient, Palliative and Supportive Care, 2014: 1-8.

Skeath P, Norris S, Katheria V, White J, Baker K, Handel D, Sternberg E, Pollack J, Groninger H, Phillips J, Berger A. (2013). The Nature of Life-Transforming Changes Among Cancer Survivors, Qual Health Res 23: 1155-1167.

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This page last updated on 06/26/2017

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