The problem of hard-to-heal wounds is a global issue. The presence of wounds, particularly hard-to-heal ones, significantly affects patients’ quality of life. As society ages and faces growing health challenges such as cardiovascular diseases, diabetes, obesity, infections, and antibiotic resistance, it is predicted that hard-to-heal wounds will become a major clinical, social, and economic challenge. Wound treatment requires a holistic approach, as well as the involvement of multidisciplinary clinical teams (Harding, 2022).

The exact prevalence of hard-to-heal wounds in many European countries remains unclear due to the complexity of disease classification systems (such as the International Statistical Classification of Diseases and Related Health Problems–ICD-10) and inadequate epidemiological surveillance. Without national wound registries, epidemiological and treatment cost estimates are often extrapolated from data from industrialized countries with comprehensive statistics (Lazarus et al., 1994).

Venous leg ulcers occur most often in elderly individuals with chronic venous insufficiency. Due to the lack of a systematized registration process, it is not possible to provide exact data related to its epidemiology (Probst et al., 2023). In Poland, there are also no precise statistics regarding the status of hard-to-heal wounds. In the largest epidemiological study conducted in Poland so far, which included 40,095 patients of family doctors, active venous ulcers were detected in 0.55% of respondents, while the presence of active or healed ulcers was found in 1.52% of individuals. Therefore, it is necessary to conduct continuous research and establish a common methodological strategy to determine the exact scale of the problem (Jawień et al., 2011).

Patients with hard-to-heal wounds often suffer from persistent pain, stress, depression, and anxiety about an uncertain future, which can lead to social exclusion. Due to pain, limited mobility, and the need for ongoing medical care, they struggle to participate in public and family life. Many are forced to leave their jobs and social activities, leading to isolation and a decreased quality of life. Additionally, access to specialized wound care clinics and hospitals can be challenging for many patients (Kapp and Santamaria, 2017; Finlayson et al., 2017).

When planning care for a patient with a hard-to-heal wound, it is always necessary to consider not only physical limitations but also economic status, education, access to medical facilities, living conditions, and support from loved ones (Vogt et al., 2020). The economic situation can directly impact treatment and rehabilitation, as poor socio-economic conditions affect both access to healthcare services and the ability to use them (Borges et al., 2018).

According to the World Health Organization (WHO), quality of life is defined as the “individual perception by a person of their life position in the cultural context and value system in which they live, and in relation to tasks, expectations, and standards determined by environmental conditions” (WHOQOL Group, 1995). This definition presents a holistic approach, including health, social, and economic aspects. In the treatment process of venous leg ulcers, attention is often focused solely on the wound itself, whereas for many patients, whose wounds have a poor prognosis, improving quality of life becomes more important (Olsson and Friman, 2020). Quality of life questionnaires provide essential information about the domains of life that deteriorate and allow for the overall monitoring of a patient’s quality of life, helping to implement necessary interventions to improve it (Savadkoohi et al., 2023).

Quality of life questionnaires have been used for a long time among patients with hard-to-heal wounds (Eckert et al., 2023). There are many general and specific tools for assessing quality of life in patients with non-healing wounds, differing in length and complexity, which is why various studies aim to develop a standardized quality-of-life tool for patients with hard-to-heal wounds (Krupová and Pokorná, 2020). In one of these studies, an assessment of quality of life was conducted in patients included in the Comprehensive Chronic Wound Treatment Program during their first and last visit to the clinic (after 4 weeks). Implementation goal of this program is not only the treatment of hard-to-heal wounds but also prevention and education for patients and their families. The study utilized WHOQOL-BREF and Wound QoL as tools for collecting data on quality of life. After 4 weeks, higher mean values of quality of life assessment were found in all domains (Pytlak et al., 2023). The development and implementation of wound treatment strategies, which focus on improving health-related quality of life and effectively reducing costs for this patient group, is a challenge for modern healthcare systems worldwide (Olsson et al., 2019).

Successful wound treatment depends on multiple factors, including dressings, compression therapy, proper nutrition education, smoking cessation, physiotherapy, and pain management. It is proven, that stress, sleep disorders, poor nutrition, and depression also directly impact the inflammatory response, thereby hindering wound healing (Moffatt et al., 2009). However, pain management remains one of the most overlooked aspects of wound care. Many patients experience severe pain, especially during dressing changes, and while nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first choice, escalating pain frequently leads to the use of narcotics (Szkiler et al., 2024).

Pharmacological treatment should follow the World Health Organization (WHO) analgesic ladder. NSAIDs have a ceiling effect beyond which they cause adverse effects without additional pain relief. Furthermore, prolonged use of NSAIDs, corticosteroids, anticoagulants, aspirin, or other blood thinners can delay wound healing (Szkiler et al., 2024). Indeed, many patients report that the painkillers they receive are insufficient, and the wound dressing change procedure is stressful, negatively affecting their daily functioning (Herberger et al., 2011).

Differences in pain perception between women and men have been observed in numerous studies in recent years, with women showing increased pain sensitivity. Many biopsychosocial mechanisms contribute to differences in pain perception between genders, including sex hormones, genetic factors, and coping strategies for pain (Bartley and Filingim, 2013). A multicentre study found that women with hard-to-heal wounds have a lower quality of life compared to men (Reinboldt-Jockenhöfer et al., 2021).

The longer the pain lasts, the higher the probability of structural changes in the brain, particularly atrophy of grey matter. The consequences of these changes may include: difficulties in establishing social interactions, sleep problems, and an increased risk of depression. People prone to catastrophizing experience greater difficulties in rehabilitation, avoid movement, which can lead to deep vein thrombosis or pneumonia. There is also a high probability that such patients will want to take higher doses of painkillers. Additionally, stress causes excessive cortisol secretion, and its increased level may limit glucose absorption by muscles. Untreated pain contributes to an increase in cortisol levels, which, in turn, begins to destroy muscles, leading to muscle mass loss and delaying the wound healing process (Lalkhen, 2021).

All in all, pain significantly worsens patients’ quality of life. Recognizing this, the European Wound Management Association released a document, Holistic Management of Wound-Related Pain, advocating for the integration of non-pharmacological methods alongside standard pharmacotherapy (Holloway et al., 2024). One such approach is virtual reality, which serves as a distraction tool by engaging both vision and hearing. This immersive technology creates the illusion of being in a relaxing and familiar virtual environment, reducing stress and pain during medical procedures such as wound cleaning and dressing changes (Spyrka et al., 2024).

Virtual reality, as a non-pharmacological method of pain relief, has already been used in the treatment of burns (Smith et al., 2022), in the rehabilitation of burn patients (Lan et al., 2023), and as an educational and training tool in medicine (Izard et al., 2018). It has been observed that virtual reality helps improve both physical and mental functioning (Riches et al., 2023). This is particularly important in modern times, with the occurrence of various pandemics, such as COVID-19, bringing significant changes to most aspects of life, and patients themselves being more exposed to stress, low mood, and negative effects related to physical and mental health (Siani and Marley, 2021).

Using an appropriate application and introducing the patient into a state of relaxation can not only alleviate pain symptoms but also create a positive attitude toward treatment. For many years, scientists have been studying the relationship between positive thinking, quality of life, disease prevention, and treatment. Numerous studies indicate a beneficial impact of a positive attitude on health, and patients with such an attitude are less vulnerable to stress and illness (Ismail, 2023).

However, in the available literature there is no study showing the impact of virtual reality on the quality of life of patients with venous leg ulcers. Therefore, this study is original, and the results can be subject to international discussion. Virtual reality may become an essential element in the treatment process of venous leg ulcers, positively influencing all domains of life. VR has also the potential to be used during dressing changes, as emphasized by EWMA (European Wound Management Association) in recent document concerning palliative wound care.

No statistically significant differences were found between the groups in terms of age, gender, marital status, source of income, education, place of residence, source of income, ulcer surface area, and ulcer duration among the respondents from the two groups (Table 1).

According to CEAP scale, most patients suffered from superficial vein system active ulcers and venous reflux (Table 2).

The changes of values (measurement II–measurement I) obtained in the assessment of quality of life in the periods before and 7 days after wound cleansing were recorded (Table 3).

Positive results (measurement II > measurement I) indicated an improvement in the quality of life of patients in the period after wound cleansing. Negative results (measurement II < measurement I) indicated a deterioration in their quality of life after wound cleansing. These results were marked respectively in yellow (positive) and blue (negative).

In the experimental group (using VR), a significant improvement was obtained in each of the domains. It could be due to the fact, that VR technology created a sense of safety and relaxation, improving patient comfort during wound care. The least significant improvement was noted in domain D3 (social relationships), but it is still clinically significant.

In contrast, in the control group, improvement was noted only in the environmental domain (D4). In other domains, negative values were obtained, indicating a deterioration in patients’ quality of life. However, the absolute values ​​of these negative changes in the control group are much smaller than the values ​​of positive changes in the experimental group, so this deterioration may not have been clinically significant.

In the pre-wound cleansing measurement, younger individuals (under 60 years old) had a significantly higher quality of life compared to older individuals (60 years and above) in somatic domain - D1 (p = 0.045) and environmental domain - D4 (p = 0.048) (Table 3). In Measurement II, significant differences were observed only in the environmental domain (D4) (p = 0.045).

Overall analysis of the data suggest that quality of life remained higher in younger individuals, but the differences are not always statistically significant (Table 4).

The quality of life of patients in the pre-wound cleansing measurement was significantly differentiated based on the duration of their illness (p < 0.05). Patients who had been ill for a shorter period (up to 6 months) always reported a higher quality of life compared to those who had been ill for more than 6 months.

In the post-wound cleansing measurement, significant differences between the two groups (patients with disease duration up to 6 months vs over 6 months) were observed in psychological domain (D2), social domain (D3) and environmental domain (D4) (p < 0.05) (Table 5).

However (independently of statistical significance) patients who had been ill for a shorter period (up to 6 months) had a higher quality of life compared to those who had been ill for more than 6 months (Table 5).

In the treatment of hard-to-heal wounds, several factors may affect patient adherence to medical recommendations. Quality of life questionnaires can assist in identifying potential barriers to effective treatment.

According to the research conducted by Domingues et al. (2016) and Vieira and Araújo (2018), which used two different tools to assess quality of life in patients with hard-to-heal wounds, most respondents had a low education level and a low family income. Both low education levels and low family income can contribute to longer treatment times and impact patients’ quality of life. For most families, income is focused on meeting basic needs such as food, clothing, and education, while additional treatment costs can affect their living conditions. Additionally, patients with low education levels may have difficulty understanding how to follow self-care guidelines (Oliveira et al., 2013). Our findings revealed that the majority of participants had completed secondary education - 55%. However, 28.3% had vocational education, which may have impacted their level of comprehension regarding clinical guidelines and instructions.

Hard-to-heal wounds affect all spheres of life, particularly the professional activity of patients, whose absence from work becomes so significant that they are forced to transition to early disability pension or retirement (Szewczyk et al., 2015). Research undertaken by Szewczyk et al. demonstrated that, 52% of patients received a disability pension, 85.7% of respondents had to temporarily give up work, and venous leg ulcers were the main reason for early retirement (Szewczyk et al., 2007). Chase’s study, using the SF-36 questionnaire, showed, in turn, that venous leg ulcers cause longer absences from professional activity (Chase et al., 2000). Our experiment confirmed that the primary source of income for most patients was a disability pension or sickness allowance (Table 1). This financial limitation may hinder the treatment process, especially if patients are required to purchase specialized dressings more frequently. In our study, we applied in all 60 patients a non-adherent copper wound dressing that could be maintained on the wound for up to 7 days at any stage of the healing process (Melamed and Borkow, 2023; Borkow and Melamed, 2025).

Age, gender, marital status, and duration of illness are also factors analyzed to determine correlations between them and the quality of life of patients. The aging society is at risk of developing hard-to-heal wounds, as there is a negative relationship between the wound healing process and age (Wicke et al., 2009). In a study conducted in primary healthcare in Singapore among patients with hard-to-heal wounds, the average age of patients was 61.2 years (Zhu et al., 2022), while in other studies, such as in Germany it was 65.3 years (Blome et al., 2014), and in Brazil it was 61.0 years (Vogt et al., 2020). Throughout our study, we identified, the average patient’s age was 62.28 years, which is a similar value to studies conducted by other researchers. A negative impact of age on the domain of vitality and mental health was observed in a study conducted in Brazil, where the SF-36 quality of life questionnaire was used (Dantas et al., 2022). The present study observed that younger individuals, under the age of 60, had a significantly higher quality of life–particularly in the somatic and environmental domains–compared to older individuals aged 60 and above (Table 4).

Many patients with venous leg ulcers experience discomfort due to the existing wound, and this feeling is further intensified by exudate and wound odor. This often leads to withdrawal and limitation of social contacts. Ironically, although social contacts become rarer, patients become increasingly dependent on their families for care (Hareendran et al., 2005). According to empirical findings, individuals who are separated or divorced have been shown to experience a diminished quality of life, especially regarding physical and emotional functioning (Dantas et al., 2022). Family support turns out to be essential in the wound healing process and significantly impacts patients’ quality of life (Lamotte et al., 2022). In our study, the majority of patients were married (Table 1), which could have translated into support and assistance with wound care and adherence to recommendations, such as the use of compression therapy, which is a necessary element in the treatment of venous leg ulcers.

The duration of illness also plays an important role in the quality of life of patients with hard-to-heal wounds. An investigation performed by Zhu et al. showed a worsening in the range of motion among patients who had been ill for more than 6 months (Zhu et al., 2022). Other studies have also noted a decline in quality of life among patients who had been ill for more than 6 months (Hopman et al., 2014; De Oliveira et al., 2019). Similarly, our findings revealed that patients with a shorter illness duration (up to 6 month) reported a higher quality of life compared to those who had been ill for more than 6 months. Thus, our experiment confirmed significant differences between the two groups in the psychological, social, and environmental domains (Table 5).

Virtual reality (VR) enables users to immerse themselves in virtual simulations of natural environments, thereby facilitating the experience of the benefits associated with exposure to nature without the necessity of physically visiting these locales. This technology engenders a sense of presence that promotes profound relaxation and concentrated attention, which are essential elements of mindfulness practice (Riva, 2005). Indeed, our study using the Guided Meditation VR application shows that virtual reality is helpful in improving quality of life, and its effectiveness is supported by research from other scientists. In particular, the use of nature elements has a beneficial impact on mental health.

In research conducted by Ma et al. (2025), preliminary evidence has been presented regarding the efficacy of brief virtual reality-based mindfulness interventions in mitigating symptoms of depression and anxiety among university students. A total of forty-nine university students participated in this quasi-experimental research, which involved assessments at three distinct time points (pre-intervention, post-intervention and follow-up). The results demonstrated that the intervention produced an immediate and statistically significant reduction in anxiety and depression symptoms, alongside improvements in mindfulness, olfactory perception, chemosensory functioning, and sensory imagery. Importantly, the observed decrease in symptoms of depression and anxiety was sustained for 1 week following the intervention (Ma et al., 2025). Our experiment confirmed that exposure to virtual reality during wound cleansing had a positive impact, as observed during the follow-up visit. In the experimental group (using VR), a significant improvement was obtained in each of the domains (Table 3).

The integration of mindfulness practices with exposure to natural environments has been demonstrated to produce substantial enhancements in mental health, particularly in mitigating symptoms associated with anxiety, depression, and cognitive fatigue (Hanley et al., 2017). Natural settings have historically been acknowledged as potent facilitators of mindfulness practices, chiefly due to their capacity to promote cognitive restoration and enhance emotional wellbeing. Consequently, specific natural scenes, including oceans, flowers, rivers, and forests, are frequently incorporated to support mindfulness practice (Ma et al., 2023). The WHOQOL-BREF scale used in our study includes a question regarding the experience of negative feelings such as depression, despair and anxiety (D2 – Psychological health), which significantly impact the healing process and cooperation with the patient. Our experiment confirmed that the use of nature-based applications has potential in distracting patients during painful procedures such as wound debridement.

Other numerous studies have also substantiated the efficacy of virtual reality (VR)-based interventions in enhancing mental health outcomes, particularly concerning anxiety and depression. For example, Failla et al. (2022) identified that VR-enhanced mindfulness interventions were linked to significant reductions in symptoms of anxiety and depression. In a similar vein, Navarro-Haro et al. (2017) demonstrated that VR-facilitated mindfulness could augment mindfulness engagement by immersing participants in tranquil, nature-based virtual environments. These studies underscore the potential of VR to not only replicate natural surroundings but also to intensify the advantages of mindfulness by providing users with a fully immersive and distraction-free experience that fosters emotional regulation and cognitive restoration.

To sum up, a holistic approach to patients with venous leg ulcers may be the key to effective treatment based on good cooperation between patient and medical staff. In the present study, the collected data allowed for the identification of obstacles in the treatment process and the determination of the role of virtual reality in improving quality of life across specific domains. So far, no similar study has been conducted. Distraction through virtual scenes such as forests or beaches during dressing changes may prove to be crucial for patients with hard-to-heal wounds.