Pain and Palliative Care

NIH Healing Experience of All Life Stressors (NIH-HEALS)

About the NIH-HEALS

Healing Experience of All Life Stressors (NIH-HEALS) was developed 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, 35-item questionnaire.

NIH-HEALS was developed by the observation that some patients with life-threatening and/or severe 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.

NIH-HEALS Versions

For More Information

Use of NIH-HEALS is free. For registration and permission to use the NIH-HEALS or for further information, contact:

Ann Berger, MSN, MD


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 the NIH-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 and an accepting attitude
  • stressors
  • depth of relationship with family, friends, and other people

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

  • a factor analysis study
  • a cognitive interviewing study

These two studies, the factor analysis and the cognitive interviewing, assisted in refining the NIH-HEAL's questions and to also reduce the items from 54 to 42. The initial examination of the factorial structure with 100 patients revealed a four factor structure.

Cognitive interviewing which is a highly recommended technique to improve the validity and relatability of questions in surveys and questionnaires was also utilized. 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. Cognitive interviewing was performed with 36 patients to refine the questions.

Our most recent study to confirm the factorial structure and validate the NIH-HEALS was conducted with 200 NIH Clinical Center patients with severe and or life threating illness and included exploratory factor analysis, principal component analysis, reliability, convergent validity, and divergent validity analyses. Item-reducing principal components analysis and internal consistency and split-half reliability demonstrated excellent internal consistency and split-half reliability.

Exploratory factor analysis revealed a three-factor structure: 

  1. Connection—belief in and connection to a higher power, religion, religious community, and family; 
  2. Reflection & Introspection—finding meaning, purpose, gratitude and joy in nature, activities including those that connect mind and body, interconnectedness, present moment orientation, and an increased sense of awareness about the fragility of life; and 
  3. Trust & Acceptance—accepting what is, feeling resolved, feeling at peace, and trusting that caregivers, friends, and family will respond to needs as they arise. 

To improve the factor structure, 7 items were excluded and the final validated version is a 35-item questionnaire (see Ameli et. al. 2018 for details).

Recent Publications

Ameli R, Sinaii N, Luna MJ, Cheringal J, Gril B, Berger A (2018) The National Institutes of Health measure of Healing Experience of All Life Stressors (NIH-HEALS): Factor analysis and validation. PLoS ONE 13(12): e0207820. https://

Coats, H., Rosenfeld, A., Crist, J., Sternberg, E., & Berger, A. (2018). Using cognitive interviews to improve a Psychological-Social-Spiritual Healing Instrument: Voices of Aging African Americans with Serious Illness. Appl Nurs Res. 2018 Feb:39:109-114.

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.

NOTE: PDF documents require the free Adobe Reader.

This page last updated on 06/28/2022

You are now leaving the NIH Clinical Center website.

This external link is provided for your convenience to offer additional information. The NIH Clinical Center is not responsible for the availability, content or accuracy of this external site.

The NIH Clinical Center does not endorse, authorize or guarantee the sponsors, information, products or services described or offered at this external site. You will be subject to the destination site’s privacy policy if you follow this link.

More information about the NIH Clinical Center Privacy and Disclaimer policy is available at