Advancing Wound Balance: Clinical perspectives and practical approaches for implementation in France

Introduction

Non-healing wounds are now considered a silent epidemic that deteriorates patients quality of life and leads to a significant burden on clinicians and healthcare systems (National Library of Medicine, 2025). With the global projected rise in risk factors for non-healing wounds, it is paramount to address this situation by fostering proactive clinician-patient partnerships and aiming for wound healing as early as possible (Carter et al, 2023; Sen, 2023). This goal can only be achieved through developing a holistic picture of each wound and patient and implementing a comprehensive treatment strategy that can be tailored to each wound, patient and clinical setting, while optimising available resources.

Wound Balance is a multifaceted concept that addresses the interconnected aspects of wound healing and clinical practice (Garten et al, 2023; Blome et al, 2024; World Union of Wound Healing Societies [WUWHS], 2025).

It seeks to integrate key wound management parameters that ensure continuity, individualised care and informed clinical decision-making, all with the patient at the heart of treatment. At its core, Wound Balance represents a shift from merely managing wounds to actively pursuing healing at the earliest possible stage (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). The patient and clinician navigate this journey together, with the patient’s quality of life, personal preferences and expected clinical outcomes shaping the decision-making process. Engaging patients in their care is essential, not only for achieving agreed treatment goals but also for enhancing their overall experience and engagement.

A panel of French wound care healthcare professionals convened to explore this straightforward and adaptable concept applicable to all wound aetiologies, ultimately determining that Wound Balance is a valuable asset in their daily practice. This publication explores the concept of Wound Balance and shares experiences of its implementation into French clinical settings. It summarises the panel recommendations and provides a comprehensive understanding of the importance of early intervention and the effectiveness of superabsorbent dressings containing polyacrylate polymers (SAPs) as optimal therapeutic solutions.

Ongoing challenges in managing wounds in French care settings 

One of the ongoing challenges in wound management is bridging the gap between expert clinicians and primary care nurses in their knowledge and skills base. Often, primary care nurses are responsible for most day-to-day wound care but may have limited access to advanced training or specialist expertise. This can create a discrepancy between the vision and goals of wound care experts and the practical realities of care delivered in community settings. As a result, this gap may lead to inconsistencies in wound assessment, treatment selection and the implementation of evidence-based practices. .

The importance of training primary care providers, including wound care nurses, general nurses and general practitioners, surrounding the Wound Balance framework was strongly emphasised by the panel. Ensuring primary care providers are familiar with its simple and adaptable principles may support earlier and more consistent interventions. In addition, support from expert nurses for generalist nurses was highly recommended, fostering a deeper understanding of wound care challenges and optimal therapeutic solutions through peer learning and mentorship. 

The panel also shared their own holistic approach to wound care, highlighting that dressing efficacy depends on multiple factors beyond the product itself. Effective management requires the implementation of clinical protocols related to wound hygiene, debridement and early intervention. These elements are closely linked to the knowledge and education of nurses, reinforcing the importance of comprehensive wound care training. Debridement was highlighted as a distinct and essential component of intervention, with autolytic methods identified as suitable for use by generalist healthcare professionals.

Additionally, telemedicine has proven effective in many regions across France and presents further opportunities for expansion in wound care services. Effective teleconsultations require not only clear prescriptions and implementation methods but also active support for carers, who often benefit from guidance provided directly at the patient’s bedside. Telemedicine creates valuable opportunities for education and shared practice, yet challenges persist in the integration of data and in ensuring that carers feel confident when applying remote guidance. Permanent wound consultations and treatment guidance are already being delivered through telemedicine, illustrating its practical application while highlighting the need for continued pedagogical and operational improvements.

Language barriers between clinicians and patients were highlighted as a potential consideration, including cases of patients unable to understand or speak French, leading to difficulties in fully understanding treatment options and wound care advice. These language barriers can lead to feelings of isolation and delays in accessing timely specialist advice. This often results in wounds becoming non-healing through sub-optimal wound dressings and limited understanding of wound management. Ideally, appropriate patient education and communication can assist patients becoming active partners with clinicians. Information about disease and treatment should be provided to the patient in simple, understandable terms for the patient to feel reassured and in control. The notion of a good therapeutic alliance is, therefore, key to ensuring that the patient is involved and understands their condition. 

Finally, the panel noted an increase in wound diagnoses among individuals with diabetes and pressure ulcers, alongside a decline in consultations for preventive care. Early intervention was deemed crucial for wounds with red flags to reduce risks such as increased exudate, slough and necrosis, and declining patient quality of life. 

Feedback in implementing Wound Balance in French clinical settings

What is Wound Balance
Wound Balance is a concept translated into simple practical processes of achieving a dynamic balance between wound care needs, patient-centric decisions and clinical practice challenges (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). 

The panel agreed that the goals of Wound Balance were to:

• Understand the science of wound healing so the wound microenvironment can be shifted towards healing
• Identify what may be preventing a wound from progressing, including external factors and wound healing barriers
• Recognise wounds likely to become non-healing through training and education of wound care providers in primary care
• Understand the importance of adopting a patient-centred approach, by identifying the patient’s individual needs and ensuring the patient is at the centre of all decision-making processes — a process that continues at every stage of the patient journey
• Use positive language to optimise wound healing rather than just managing wounds
• Consider and measure patient quality of life, social determinants of health and the impact of living with a wound to improve outcomes and build evidence
• Apply the knowledge gained to achieve optimal outcomes in an appropriate and timely manner.

Active patient engagement is crucial for achieving optimal wound healing results and improving the overall care experience (Wounds International, 2023). It was highlighted the Wound Balance approach fosters a collaborative partnership between the patient and clinician, placing the patient’s quality of life, preferences, and anticipated clinical outcomes at the heart of decision-making.

A key aspect of Wound Balance is the regulation of physiological factors within a wound microenvironment so the wound can be placed back on a healing trajectory (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). This can be achieved by understanding the role of wound biomarkers and their impact on potential healing barriers.

Balancing the wound trajectory – understanding the non-healing biomarkers

The biomarkers of non-healing
An understanding of the pathophysiology of wound repair and how this relates to the individual patient and their wound in a particular clinical setting can help achieve a shift in treatment focus toward early intervention and healing. This can improve healing and quality of life outcomes. Several intrinsic and extrinsic factors can interfere with one or more phases of the healing process, leading to impaired or delayed wound healing (WUWHS, 2025). Notably, inflammation plays a key role in a normal wound healing trajectory; a prolonged inflammation phase is a hallmark of non-healing wounds (WUWHS, 2025). The panel agreed that it is unrealistic to assess biomarkers for each non-healing wound in each clinical setting. However, certain clinical signs can indicate a biomarker imbalance toward non-healing. For example, excessive exudate, fibrin and slough, along with increased pain, malodour and delayed wound healing, may indicate a disrupted healing process (WUWHS, 2025). The panel highlighted the obvious need to control bioburden in the wound and avoid infection.

The panel acknowledged that, despite identifying and addressing the barriers to healing, certain wounds may persist in a non- healing state without an identifiable cause. However, for a majority of non-healing wounds, the concept of Wound Balance can help identify these barriers by improving clinician awareness and supporting early intervention with the scope to shift to normal healing.

Focus on patient’s quality of life 

An in-depth patient-centred assessment is essential to identify key outcomes for wound management while maintaining quality of life outcomes. Depending on the healthcare setting, there are several assessment constraints. Limited time, access to resources and differences in clinicians’ knowledge and expertise are common challenges. However, experienced clinicians can often notice and assess a patient’s functional abilities throughout every contact, paying special attention to their demeanour, cognition, emotional state and abilities. A comprehensive wound assessment, therefore, encompasses not only assessing the wound but also taking a whole-person approach to evaluating the patient. 

Factors that may affect the patient’s healing and well-being can be generally categorised as intrinsic (related to the patient and their health) and extrinsic (relating to outside factors such as environment and care).  It is important to explore intrinsic factors such as:

• The patient’s medical history
• Overall health/wellbeing in the past and present moment; it is important to establish the patient’s baseline and what is ‘normal’ for them
• Any underlying factors that may affect healing – e.g. health conditions, medications, chronic illnesses and nutrition
• The wound characteristics
• Wound-related history – e.g. has the patient had a wound previously (or a recurring wound) and how did that wound heal?
• The surrounding skin and general skin integrity
• The patient’s mobility, nutritional status, smoking/alcohol use.

It is also important to take the opportunity to assess less direct factors such as:

• The patient’s support network, including caregivers, friends and family
• Environment and hygiene
• Psychosocial factors
• The financial impact of living with a chronic wound
• Level of education and literacy
• Financial resources
• Access to medical care
• Transportation and mobility
• The personal impact on the patient of living with a wound.

Impact of living with non-healing wound and potential preventive measures

Wound Balance embraces the patient’s overall health and wellbeing, incorporating physical, psychological and lifestyle factors (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). Living with a wound can significantly affect quality of life, with challenges such as pain, malodour, exudate, mobility restrictions and limitations in activities of daily living. These difficulties may also contribute to psychological distress, social isolation, or reduced adherence to care, highlighting the importance of empathy, active listening and shared decision-making.

The discussion emphasised that pressure ulcers are not inevitable but largely preventable, making prevention a priority and a structural quality and safety indicator for healthcare systems. Effective prevention requires organisation, education, monitoring and integration into policy. When ulcers do occur, management must be individualised, addressing not only local wound care but also the broader life context and goals of each patient, whether a young paraplegic or an older person approaching end of life.

At the core of prevention and treatment is the therapeutic alliance between patients and carers. Trust, open communication and patient engagement are essential for promoting adherence and improving outcomes. The concept of Wound Balance provides a valuable framework for integrating preventive and therapeutic strategies through ongoing assessment, adaptation and dissemination across healthcare teams (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). Ultimately, the goal is to prevent pressure ulcers whenever possible, while ensuring that treatment, when needed, remains grounded in prevention, holistic care, and patient-centred collaboration.

Tailoring care to the individual
The concept of Wound Balance includes balancing the patient’s individual needs and expectations, as well as the physiological healing factors (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). Starting with assessment, it is important to listen to the patient’s individual needs and preferences, and tailor care accordingly. Different patients will have different priorities, which can change over the course of the wound healing trajectory, and these may also differ from the priorities of the clinician. For example, a patient may have a particular goal or event in mind, such as being able to work or attend a particular social occasion without having to worry about their wound. It may be useful to ask the patient direct questions to establish their individual priorities before commencing treatment, such as (WUWHS, 2020):

• What are your priorities regarding your wound and dressing selection?
• What are your goals to help you live with your wound and improve your quality of life?
• Are there any lifestyle issues we should bear in mind?
• Do you have any concerns?
• Do you have any questions about how the dressing will work?

It is important to remember that patient capacity and cognition will vary, and some patients may need additional support. This may include additional assistance where there is limited mental capacity, literacy issues, language barriers, mental health concerns, practical issues such as mobility and environment, and the support that a patient has available to them. Talking to the patient clearly and assessing their capacity and willingness to engage will help to maximise the efficacy of treatment. Particularly in terms of long-term treatment (e.g. compression), it is important the individual understands the commitment and what requirements are necessary. Access to appropriate treatment and devices, such as offloading, and options that may benefit the patient should be considered.

As well as considering the needs and capacity of the patient, their relatives and any informal carers should also be considered. Patient support is a critical consideration when developing a treatment plan (Moore, 2016). It may be worthwhile considering using tools such as building a patient mind-map with the patient at the centre and mapping the support that the patient has available.

Ownership and responsibilities in wound care
Making care accessible and ensuring the patient fully understands their treatment and plan is key to outcomes. Clinicians should communicate clearly and avoid complicated language, jargon and medical terminology, taking the time to make sure the patient understands. Patients should be offered information in a format that suits them, and guidance should be followed to make sure capacity is fully considered, such as:

• Discussing the patient’s care and options in a time and place that helps the individual to understand and remember what is said
• Asking whether having a friend or relative present might help them to remember information or help them to make a decision
• Offering audio or written information if this will help, considering any potential language barriers or literacy issues
• Speaking to the patient’s friends, relatives and others in the healthcare team about how best to communicate with the individual.

Creating a friendly and calming environment wherever possible can help to reduce patient anxiety and improve engagement. In the clinical environment, asking the patient how they are, offering a drink or even playing background music can make a difference to the patient’s overall experience and how they feel about the care they receive; if visiting the patient at home, where such resources may not be available, it is useful to ask the patient what helps to relax them. 

While ‘getting it right first time’ is always a priority, there may be challenges in practice.

Limited time and resources place significant pressure on clinicians, making an honest and realistic approach important in managing patient expectations and maintaining satisfaction. Workforce shortages remain a critical issue, shaped by complex factors, with ongoing efforts to strengthen recruitment and retention strategies (Roth et al, 2022).

The language used in wound care also matters. Terms such as “non-compliant” or “non-concordant” can be counterproductive, potentially creating barriers to care (WUWHS, 2020). Non-concordance should be seen as a signal of communication breakdown rather than patient fault, underscoring the clinician’s role in fostering a therapeutic, collaborative relationship to find workable solutions together.

Prioritising Wound Balance and focusing on wound healing are crucial to optimising the use of limited resources, ultimately alleviating the burden on patients, healthcare professionals, and the broader healthcare system (Blome et al, 2024; WUWHS, 2025).

Clinician experience of Wound Balance 

The French panel perceive Wound Balance as a simple and adaptable concept that can be readily implemented in practice to support early intervention across multiple wound aetiologies.

While prioritising the concept of Wound Balance, the panel emphasised the need to address several key factors that influence successful implementation:

• Access to healthcare: Ensuring patients have adequate coverage to support timely and effective wound care
• Access to expertise and early diagnosis: Facilitating prompt specialist intervention and accurate assessments to improve patient outcomes
• Patient care: Strengthening healthcare worker competence/capability through clear, structured training to enhance the quality of wound management.

Depending on the wound type and identifiable red flags (e.g. risk of infection or the presence of biofilm), French clinicians recommended debridement as the first stage of intervention.In this situations, Hydro-Responsive Wound Dressings (HydroClean®; Ousey et al, 2016; Sterpione et al, 2021) permit cleansing and autolytic debridement, which is advantageous for patients who are immobile or in situations where mechanical debridement cannot be performed. 

In practice, selecting the appropriate dressing can help mitigate or even reverse factors that hinder wound healing. Thoughtful decision-making in wound management plays a crucial role in promoting healing and preventing high-risk wounds from becoming non-healing (Humbert et al, 2014). The Wound Balance approach, through the use of SAP dressings, can be utilised for preventive, curative and palliative wound care strategies. The panel of healthcare professionals shared their experience of treating patients with SAP-dressing and highlighted the significant benefits recorded. Specifically, the benefits were highlighted of employing HydroClean® for autolytic debridement (Ousey et al, 2016; Sterpione et al, 2021) and RespoSorb® Silicone Border for managing exudate and protecting the surrounding skin of all types of wounds (Barrett et al, 2022; Ball et al, 2025).

Debridement – a critical step to balance wound microenvironment 
Debridement is the removal of necrotic, devitalised and/or infected tissue to help balance the wound environment and promote healing. Debridement reduces microbial and biofilm burden, minimising the risk of infection and further complications that may delay healing. Therefore, debridement is a crucial step in balancing the wound environment, by converting the wound back to an acute state and removing the barriers to healing (Thomas et al, 2021). A proactive approach to debridement is recommended to improve healing potential before a wound may become non-healing. 

However, approaches to and achievement of debridement may vary significantly, depending on care settings, clinician skill and practitioner confidence. The ability to identify wounds that require debridement and the most effective method of debridement to be applied depends on the aetiology of the wound, patient state of health, contraindications or pain as an important factor for patient quality of life. There are several approaches to debridement and some of these do not require a high level of clinical expertise and reflect the availability in any clinical facilities. 

One such method is autolytic debridement which uses the body’s own enzymes to remove slough and devitalised tissue, a process undertaken through specialised wound dressings (e.g. Hydro-Responsive Wound Dressing (HRWD) containing SAP) or topical agents (Nair et al, 2024). Autolytic debridement is commonly used in France and, in routine wound care settings, is a key step in wound bed preparation. Generalist nurses or physicians can perform autolytic debridement without the requirement for specialist training.

The panel discussed the application of SAP dressings across various wound aetiologies and healing stages, emphasising that SAP dressings can be used throughout the healing journey, from the initial phase when debridement may be necessary until epithelialisation when exudate is no longer present. SAP dressings, such as RespoSorb® Silicone Border (Barrett et al, 2022; Ball et al, 2025) and HydroClean® (Ousey et al, 2016; Sterpione et al, 2021) with their capacity to bind and remove healing inhibitors (e.g. proteases in excess and microorganisms), promote a balanced wound microenvironment required for achieving healing goals in most clinical settings (Probst, 2019; Candas et al, 2021; Veličković and Prieto, 2022; Veličković et al 2024).

In addition to debridement, effective exudate management is also crucial for removal of non-healing factors from the wound microenvironment.

Exudate management with SAP dressings 
Although the production of wound exudate is a necessary part of the healing process, excessive exudate can adversely affect wound healing (WUWHS, 2025).

SAP dressings can be used for exudate management, ease-of-use and continuity of care. In a recent assessment of SAP dressing performance in a range of wound aetiologies across various clinical settings, a significant improvement in exudate management, healing outcomes and continuity of care were noted (WUWHS, 2025). 

The panel therefore recommends the use of evidence-based exudate management approaches that are accessible to clinicians and patients across a variety of care settings in France.

Key points and recommendations 

Living with a wound can have a severe impact on patient quality of life and this has a key role to play in all treatment (WUWHS, 2020). The quality of life of patients living with chronic wounds is often considered poor according to qualitative evidence based on patients’ own perspective (Vogt et al, 2020) and quantitative research (Kapp and Santamaria, 2017). It is crucial to consider patient preferences and priorities at every stage of treatment, aiming to minimise the adverse effects of living with a wound on the lives of patients. , Traditionally, quality of life has been a factor that is difficult to quantify; additionally, living with a chronic wound has a unique impact that is different from other chronic conditions, which is not necessarily considered. For example, there are specific wound-related quality of life factors that can have a substantial impact and cause anxiety or isolation (e.g. exudate/leakage, malodour) that are not included in most patient quality of life assessment tools. Patients have reported that living with a chronic wound is not taken as seriously as living with other chronic conditions (WUWHS, 2020). Additionally, some wound treatments, such as compression, can involve a significant long-term commitment that may be difficult for the patient to fit into their lifestyle, which causes a unique set of issues. 

From a clinician perspective, clear and honest communication is required to establish realistic goals and priorities based on the patient’s needs and preferences. It is paramount that treatment is need-based, not just medically based, and offering alternatives (e.g. different compression systems or wraps as opposed to bandages) for suitable patients may be beneficial (Corbett and Ennis, 2014). 

Listening to the patient and actively involving them in their own care and treatment can positively benefit wound healing, patient engagement and quality of life. In tracking patient outcomes, it is important to continue to monitor patients beyond healing if possible. Recurrence in wounds such as venous leg ulcers is common, with over half of all wounds likely to recur within 12 months (Finlayson et al, 2018). In this case, compression therapy should be seen as a long-term treatment, and it is important to continue to monitor the patient and their wellbeing if possible.

The panel agreed that gathering information about patient quality of life is beneficial on an individual level and can provide scope for change, providing evidence that can inform practice and make a difference. Many patients have developed coping strategies that may mean their issues are not visible. 

Achieving Wound Balance requires the effective use of tools, with patients undergoing continuous assessment and reassessment to track progress and identify potential challenges along their healing journey (Garten et al, 2023; Blome et al, 2024; WUWHS, 2025). An understanding of both wound healing science and the individual patient is fundamental to this concept. When clinicians recognise the patient’s wound, overall health, and wellbeing, they can address critical issues and minimise barriers to recovery. Actively involving patients in their care, fostering trust, and enhancing their overall experience have been shown to improve outcomes (WUWHS, 2020). Prioritising the patient’s quality of life and recognising what matters most to them as an individual can positively influence every stage of the healing process.

A well-structured approach not only supports better patient care but also optimises clinical time and resources, reducing costs and easing pressure on healthcare systems. Accurate assessment of patient risk and needs enables clinicians to focus on those requiring greater attention, ultimately enhancing overall outcomes. 

To truly advance wound care, a shift in focus is necessary to one that prioritises wound healing rather than just management. This transformation requires a solid understanding of both the science of wound healing and the unique needs of each patient. The panel emphasised the importance of early prevention of complications as being an integral aspect of hospital care to maintain and improve quality of life outcomes for the patient.

Finally, the panel has specific recommendations that can help improve patient’s quality of life:

• Doctors and healthcare providers are not simply treating a wound; they are treating the whole patient
• A comprehensive assessment is key but can be a challenge due to practical factors such as time or staffing constraints, therefore more than one visit may be required to obtain a full picture of the patient’s healing needs
• While conducting a full assessment, consider the patient’s treatment plan and what can be applied to help the Wound Balance journey and prevent deterioration
• As part of assessment, it is important to consider extrinsic versus intrinsic and direct wound related factors that may affect the patient’s healing and general wellbeing
• It is important to establish the patient’s individual priorities (e.g. odour and leakage) and to tailor this to factors such as their environment, and the support they have available
• Communication with the patient (and within teams) is critical and any potential barriers, such as language or capacity, must be addressed wherever possible
• It is essential that both the clinician and the patient take ownership and accountability, and that the patient is at the centre of all decision-making processes
• Reviewing language and ensuring that the patient understands their treatment has been found to improve outcomes
• The patient, along with their friends, family or carers, should be considered an important part of the healing trajectory
• There should be focused wound care education for all healthcare professionals
• Always listen to the patient.

Educating individuals about the concept of Wound Balance is a critical step in enhancing global patient care and overall quality of life. Clinicians stressed the need for improved hospital care, where carers are encouraged to build trust with one another and take the time to listen to their patients. The demands of acute care settings must also be carefully considered, particularly regarding the timely implementation of preventive strategies. These strategies are often overlooked in favour of reactive treatment, which tends to take precedence. Shifting the focus toward proactive care can significantly improve patient outcomes and reduce long- term complications.