# Emerging Voices From the Frontline: Perspectives of Advanced Practice Nurses and Peer-Helpers in French Mental Health Settings

Nancy de Jesus, Damien Croguennec, Margot Morgiève

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Nancy de Jesus, Damien Croguennec, Margot Morgiève. Emerging Voices From the Frontline: Perspectives of Advanced Practice Nurses and Peer-Helpers in French Mental Health Settings. Perspectives in Psychiatric Care, inPress, 2025, pp.9002919. 10.1155/ppc/9002919. hal-05357357

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Research Article

# Emerging Voices From the Frontline: Perspectives of Advanced Practice Nurses and Peer-Helpers in French Mental Health Settings

Nancy De Jesus ID<fnref n="1" />,<fnref n="1" />,<fnref n="2" />,<fnref n="3" /> Damien Croguennec ID,<fnref n="4" /> and Margot Morgiève ID<fnref n="1" />

Correspondence should be addressed to Nancy De Jesus; nancy.dejesus@ght94n.fr

Received 7 January 2025; Revised 7 August 2025; Accepted 3 October 2025

Academic Editor: Francisco Sampaio

Copyright © 2025 Nancy De Jesus et al. Perspectives in Psychiatric Care published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

**Background:** Globally, the emergence of advanced practice nurses (APNs) and Peer-Helpers is transforming mental health systems by addressing workforce shortages and user-centred care. In France, where mental health has recently been designated a national priority, the lived experiences and perceptions of these emerging professionals remain underexplored. This study investigates how APNs and Peer-Helpers construct their professional identities and navigate the tensions and power dynamics surrounding their integration within mental healthcare settings.

**Aim:** To comparatively explore the professional identities, lived experiences, and integration challenges of APNs and Peer-Helpers within France's mental healthcare system.

**Design:** Descriptive qualitative research using in-depth data collection.

**Method:** Semistructured interviews were conducted with six APNs and six Peer-Helpers from diverse mental healthcare settings across France. Data were analysed using reflexive thematic analysis, identifying themes and patterns in participants' perspectives and lived experiences.

**Results:** Participants described persistent barriers to legitimacy, including unclear scopes of practice, institutional resistance, and epistemic asymmetries within clinical teams. While APNs struggled with medical hierarchies, Peer-Helpers faced symbolic inclusion coupled with structural marginalization. Despite these tensions, both roles developed forms of adaptive boundary work to assert relevance in team collaborations.

**Conclusion:** The study reveals that professional integration is not a linear or neutral process but marked by role conflict, emotional labour and jurisdictional negotiation. These findings challenge normative assumptions about role innovation as purely technical solution and invite a more nuanced, practice-based understanding of systemic change.

**Implications for the Profession and/or Patient Care:** To our knowledge, this is the first comparative study of APNs and Peer-Helpers in France. It shows that their complementary contributions, clinical expertise and experiential knowledge, remain underleveraged due to institutional inertia and entrenched hierarchies. Internationally, these findings urge policymakers and health leaders to reconsider professional integration not as a rigid implementation, but as contested labour that demands interpersonal trust, structural support and epistemic equity.

**Patient or Public Contribution:** None.

**Keywords:** advanced practice nurses; epistemic justice; healthcare organization; mental health; peer-helpe; professional identity; role integration; service transformation

<footnote n="1">¹INSERM-CERMES3, Université Paris-Descartes, 45 Rue des Saints-Pères, Paris 75006, France</footnote>

<footnote n="2">²ESM, Faculty of Health, Université Paris-Est Créteil (UPEC), 2 Rue Antoine Etex, Créteil 94000, France</footnote>

<footnote n="3">³Reference Center for Limb Malformations (CEREFAM), Paris Est Val-de-Marne Hospitals (Saint-Maurice Site), 14 Rue du Val d'Osne, Saint-Maurice 94410, France</footnote>

<footnote n="4">⁴FACOM Mobipsy75, Pole 75i01, Paris Est Val-de-Marne Hospitals (Saint-Maurice Site), 14 Rue du Val d'Osne, Saint-Maurice 94410, France</footnote>
# 1. Introduction

Mental health is a critical global issue, affecting nearly one billion people worldwide [1]. Individuals with severe mental illnesses face profound challenges, including a life expectancy 10–20 years shorter than the general population, alongside significant economic consequences, with projected global losses exceeding $6 trillion annually by 2030 [2]. These data expose the urgency of addressing mental health through effective strategies that alleviate the economic burden and meet individual needs [3].

In France, following significant public mobilization and the support of a broad collective including 3000 associations and professionals, the government has designated mental health as a “Major National Cause” for 2025 [4, 5]. This pronouncement signals a commitment to elevating mental health as a top national priority to meet the needs of its 67 million residents [6]. However, the French health system, despite its comprehensive funding for mental health, faces significant challenges, including delayed consultations, insufficient inpatient beds and an overall “psychiatry crisis” stemming from underinvestment and workforce shortages [7, 8].

To address these issues, the global evolution of mental healthcare has led to transformative developments, including the emergence of advanced practice nurses (APNs) and Peer-Helpers. These roles offer innovative perspectives, aligning with a shift from hierarchical, physician-led models to collaborative, multidisciplinary care networks [9]. Despite their potential, the experiences and integration challenges of APNs and Peer-Helpers in France remain underexplored. This study aims to address this gap by examining their professional identities, lived experiences and perceptions of integration within the mental healthcare system. Further, we acknowledge that definitions and scopes vary across and within countries, and their analysis requires careful contextualization.

# 2. Background

## 2.1. APN: Historical and Global Context.
APN emerged from a recognition of the need for expanded nursing competencies to address complex healthcare demands [10]. Visionaries like Florence Nightingale and Hildegard Peplau laid the groundwork for modern nursing and its advanced roles. Nightingale's work in the mid-1800s marked the origins of modern nursing, while Peplau, the first published psychiatric nurse theorist, introduced principles that continue to influence advanced practice roles in mental health today [11, 12].

Globally, APNs now operate in over 60 countries, addressing healthcare complexities through expanded clinical responsibilities and roles in primary care, acute care and leadership [13, 14]. In Europe, countries like the Netherlands and the United Kingdom have integrated APNs into multidisciplinary teams to address practitioner shortages, enabling them to manage tasks such as prescription renewals and alleviate systemic pressures [15].

In contrast, France has developed a unified APN role, which was officially recognized only in 2019 under Article R4301-3 of the Public Health Law, reflecting its unique healthcare context. This role offers five specializations, including psychiatric and mental health, through 2-year master's programs offered at 30 universities [16].

The integration of APNs in France, particularly in psychiatry and mental health, has faced numerous challenges. These challenges are rooted in the need to establish a collective professional identity for APNs, reduce stigma, and promote interprofessional collaboration; factors that are critical for their successful integration into the healthcare system [17]. Despite the potential of APNs to address systemic pressures and improve care delivery, their introduction has been met with resistance from traditional healthcare professionals. This resistance has sparked debates about professional boundaries, patient safety and the integrity of the healthcare system. Regional studies highlight significant stakeholder controversy, emphasizing the need for clearer role definitions and institutional communication [18, 19].

Anthropological perspectives suggest that such resistance is often rooted in deeply embedded cultural norms and professional hierarchies within healthcare systems. These systems tend to reinforce symbolic boundaries, where new roles like APNs challenge established practices and perceptions of authority. Such dynamics reflect broader patterns of professional integration struggles observed across different sociocultural contexts [20].

## 2.2. Peer-Helpers: Origins and Contributions.
Simultaneously, peer mentorship has become a key reinforcement of mental health support globally, leveraging the lived experiences of individuals to provide unique insights and empathetic care. In France, the concept began to take root in 1992 with the National Federation of Psychiatric Patients (FNAPSY) championing service-user involvement in shaping mental health policies and practices. By 2005, this advocacy culminated in the establishment of peer mentorship programs, including the Peer Mediator Bachelor's Degree at University Paris 13 and training initiatives in Bordeaux, Marseille, Lyon, and Paris [21, 22].

These programs have since expanded significantly, with more than 150 graduates contributing to 34 hospitals and 23 medico-social structures across France, including overseas territories [23]. Peer-Helpers bring experiential knowledge, a dynamic, evolving form of expertise rooted in lived experience, into multidisciplinary teams, offering complementary and distinctive perspectives in mental healthcare [24].

Peer-Helpers fulfil diverse roles, from facilitating support groups to training healthcare professionals and participating in therapeutic education. Their contributions not only reduce the burden on traditional healthcare services but also offer effective alternatives for crisis management [25, 26]. Outside the formal healthcare system, citizen-led renewals and alleviate systemic pressures [15]. In contrast, France has developed a unified APN role, which was officially recognized only in 2019 under Article R4301-3 of the Public Health Law, reflecting its unique healthcare context. This role offers five specializations, including psychiatric and mental health, through 2-year master's programs offered at 30 universities [16].
initiatives highlight how community-driven approaches can complement traditional mental health services. A notable example is *The Perched House* in Paris, a citizen-organized association that provides a supportive space for young adults with bipolar disorder or schizophrenia. By encouraging shared learning and collaborative approaches to illness management, this initiative illustrates the innovative potential of peer-driven mental health support models [27].

Socioanthropological insights further reveal how peer support redefines societal roles for individuals with mental illnesses. These initiatives create “in-between statuses,” enabling individuals to navigate stigma and societal expectations while managing their conditions [28]. By emphasizing shared experiences and collective strength, peer mentorship continues to reshape mental healthcare in France.

## 2.3. *Challenges in Integration.*
Despite their promise, the integration of APNs and Peer-Helpers faces obstacles, including ambiguous roles, interprofessional collaboration challenges and a lack of validated practice models [29, 30]. In a broader context, the pan-European Mental Health Coalition has emphasized the importance of workforce training, collaborative care, and sustainable funding to further support these emerging professions [31].

# 3. Research Question

This exploration seeks to answer the following question: How do the perceptions of APNs and Peer-Helpers regarding their roles, integration and lived experiences differ within multidisciplinary teams in France's mental health system, and What are the implications for professional dynamics and care delivery?

## 4. Objectives

This investigation aimed to uncover the lived experiences and professional role representations of APNs and Peer-Helpers in France, shedding light on how their perspectives shape clinical practices. Additionally, it sought to compare their perceptions of legitimacy and interpersonal roles within multidisciplinary teams and examine the implications of these lived experiences for team dynamics and healthcare delivery.

# 5. Method

Guided by the 21-item Standards for Reporting Qualitative Research (SRQR) as outlined by O'Brien et al. [32]; we employed a transparent, systematic and rigorous approach to qualitative inquiry, ensuring comprehensive reporting throughout all phases of the study.

## 5.1. *Study Design.*
We conducted a qualitative descriptive study to identify and interpret patterns across participants' accounts. This inductive approach prioritized interpretations grounded in lived experience, deliberately avoiding pre-existing frameworks.

## 5.2. *Sampling.*
Participants were purposively sampled to maximize variation across gender, professional role (APN or Peer-Helper), geographic location (urban and rural regions of France) and practice contexts (hospital-based and community-based). Inclusion criteria required active practice in French mental healthcare settings, with at least 6 months of experience; professionals in training or those with less than 6 months of field experience were excluded.

## 5.3. *Recruitment.*
Eligible participants were recruited via professional networks, including internal hospital communications, national nursing and peer-support associations, WhatsApp groups and mailing lists. Study invitations clearly outlined the research purpose and participation criteria. Interested respondents received detailed study information and had opportunities to raise questions before providing informed consent.

## 5.4. *Ethical Considerations.*
This study was approved by the University of Paris Research Ethics Committee (No IRB: 00012023-6) and registered with the data protection office of the French National Center for Scientific Research (CNRS). Participants provided written informed consent and were assured of confidentiality, anonymity and the right to withdraw at any stage. Data were securely stored with encrypted audio recordings and transcripts on password-protected servers.

## 5.5. *Data Collection.*
Data were collected through individual, semistructured interviews and conducted remotely using a secure, password-protected videoconferencing platform. The interview guide covered four key areas: professional identity and role formation; role transition and motivation; team integration and interpersonal dynamics; and clinical practice experiences. Following participants' consent, interviews were audio-recorded, transcribed verbatim, anonymized and stored securely. Participants were offered the option to review their transcripts to ensure accuracy and enhance data trustworthiness (see Figure 1: Data Collection Process).

## 5.6. *Data Saturation and Reflexivity.*
Following Braun and Clarke's [33] reflexive thematic analysis, we conceptualized data saturation as theoretical sufficiency rather than a positivist benchmark where no new themes emerge. Data collection proceeded until additional interviews enriched existing themes without fundamentally altering the conceptual framework, facilitating a rich and comprehensive understanding.

Reflexive practices to address researcher subjectivity and potential biases included triangulation with socioprofessional frameworks, maintaining detailed reflexive journals to documents analytic choices, collaborative dual-coding with a second researcher, to ensure interpretative consistency, and regular team debriefing sessions to challenge assumptions and resolve discrepancies. These steps enhanced analytical rigour and transparency, consistent with Braun and
<figure><img src="image_3.png" /><figcaption>FIGURE 1: Data collection process.</figcaption></figure>

Clarke's [33] emphasis on reflexivity as central to quality qualitative analysis.

5.7. *Data Analysis.* Moreover, data were analysed using Braun and Clarke's [33] six-phase process: (1) familiarization with data; (2) systematic coding in Excel; (3) identifying themes through code clustering; (4) iterative reviewing and refining of themes; (5) theme definition and naming and (6) contextualizing findings within existing literature and theoretical frameworks. A second researcher independently coded selected transcripts, and discrepancies were resolved through team discussions emphasizing on data adequacy, bias and interpretative coherence. This approach preserved both the richness of lived experience and analytic transparency (see Figure 2: Data Analysis Process).

5.8. *Rigour and Trustworthiness.* Consistent with O'Brien et al.'s [32] SRQR guidelines, we enhanced credibility through member checking, researcher triangulation (double coding) and reflexive journaling. Dependability was maintained by a comprehensive audit trail documenting each methodological decision. Transferability was supported by providing rich, thick contextual descriptions of participants' experiences, enabling others to evaluate applicability. Confirmability was ensured by grounding findings firmly in data and actively addressing researcher assumptions through collaborative reflection. Collectively, these strategies guaranteed transparency, reflexivity and methodological robustness in capturing the integration experiences of APNs and Peer-Helpers in France's mental healthcare system (see Figure 3: Methodological Rigour).

## 6. Results

6.1. *Participant Characteristics.* Out of 21 professionals who initially expressed interest in the study, 12 individuals (six APNs and six Peer-Helpers) participated in interviews lasting between 60 and 70 mins (maximum), with an average duration of approximately one hour. They represented diverse professional contexts in both hospital and community-based settings, including paediatric, adult and geriatric psychiatry

services, across various regions of France. Their ages range from 25 to 52 years (median age: 38.5 years) with equal representation of male and female participants. APNs came from varied paramedical backgrounds, while Peer-Helpers possessed diverse levels of education and prior occupations before formally engaging in mental healthcare (see Table 1).

6.2. *Overview of Themes.* Using Braun and Clarke's [33] reflexive thematic analysis, four major themes emerged inductively through iterative coding and theme refinement. These themes capture shared experiences and key distinctions between APNs and Peer-Helpers concerning professional legitimacy, role clarity, team integration and their perceived impact on care delivery. Direct participant quotations are employed to illuminate nuanced meanings and provide authentic voices.

6.2.1. *Theme 1: "Who Am I"—Crafting a Role Amid Ambiguity.* Participants described a shared struggle to define and affirm their professional identities within multidisciplinary teams, a tension that forms the core of the first theme. This struggle reflects the evolving nature of APN and Peer-Helper roles as they negotiate their place in collaborative care models.

6.2.1.1. *Similarities.* Both groups emphasized a user-centred approach, striving to prioritize the needs of service users amid ongoing efforts to claim their place in hierarchical settings where their roles are often misunderstood or undervalued.

6.2.1.2. *Contrasts.* APNs typically articulated their professional identity in terms of extended clinical responsibilities, emphasizing autonomy, decision-making authority and boundary-pushing responsibilities such as medication renewal and holistic care. One APN described their role as

*"My role involves advanced clinical reasoning, pushing the boundaries of nursing practice while almost approaching the medical realm."*
<figure><img src="image_4.png" /><figcaption>FIGURE 2: Data analysis process.</figcaption></figure>

<figure><img src="image_5.png" /><figcaption>FIGURE 3: Methodological rigour.</figcaption></figure>

<table><caption>TABLE 1: Characteristics of participants.</caption><thead><tr><td>Participant</td><td>Current profession</td><td>Previous profession</td><td>Sex</td><td>Age</td><td>Region</td><td>Practice location</td></tr></thead><tbody><tr><td>P1</td><td>Peer-Helper</td><td>Psychologist</td><td>Male</td><td>52</td><td>94</td><td>Community-based adult psychiatry</td></tr><tr><td>P2</td><td>Peer-Helper</td><td>Librarian</td><td>Male</td><td>31</td><td>93</td><td>Hospital-based adult psychiatry</td></tr><tr><td>P3</td><td>Peer-Helper</td><td>Undisclosed</td><td>Female</td><td>37</td><td>94</td><td>Community-based paediatric psychiatry</td></tr><tr><td>P4</td><td>Peer-Helper</td><td>Commercial director</td><td>Female</td><td>41</td><td>75</td><td>Hospital-based adult psychiatry</td></tr><tr><td>P5</td><td>Peer-Helper</td><td>Fashion industry</td><td>Female</td><td>50</td><td>40</td><td>Community-based adult psychiatry</td></tr><tr><td>P6</td><td>Peer-Helper</td><td>Educator</td><td>Male</td><td>33</td><td>69</td><td>Hospital-based adult psychiatry</td></tr><tr><td>P7</td><td>Advanced practice nurse</td><td>Case-manager nurse</td><td>Male</td><td>25</td><td>93</td><td>Hospital-based adult psychiatry</td></tr><tr><td>P8</td><td>Advanced practice nurse</td><td>Emergency nurse</td><td>Male</td><td>47</td><td>42</td><td>Hospital-based adult psychiatry</td></tr><tr><td>P9</td><td>Advanced practice nurse</td><td>Psychiatric nurse</td><td>Female</td><td>45</td><td>75</td><td>Community-based geriatric psychiatry</td></tr><tr><td>P10</td><td>Advanced practice nurse</td><td>Psychiatric nurse</td><td>Male</td><td>40</td><td>66</td><td>Community-based geriatric psychiatry</td></tr><tr><td>P11</td><td>Advanced practice nurse</td><td>Psychiatric nurse</td><td>Female</td><td>39</td><td>78</td><td>Community-based paediatric psychiatry</td></tr><tr><td>P12</td><td>Advanced practice nurse</td><td>Psychiatric nurse</td><td>Female</td><td>48</td><td>75</td><td>Hospital-based paediatric psychiatry</td></tr></tbody></table>

Note: Regional codes correspond to French administrative departments.

**Peer-Helpers**, by contrast, grounded their identity in their lived experience, emphasizing their capacity to build trust with service users and bridge the gap between patients and clinical teams. A Peer-Helper explained

"I use my personal recovery to bridge the gap with the team and help patients understand their diagnoses and treatment plans."

6.2.2. Theme 2: "We Are Pioneers"—Motivational and Emotional Cost of Role Innovation. All APNs and Peer-Helpers positioned themselves on the frontier of systemic change, characterized by enthusiasm for innovation but tempered by emotional strain and uncertainty.

6.2.2.1. Similarities. Both groups shared a strong intrinsic motivation and sense of mission to enhance and contribute
to a more responsive, user-centred mental healthcare system. Their decision to enter these emerging roles was often framed as a calling or mission. However, participants also reported a profound sense of emotional vulnerability linked to being early adopters in roles not yet fully legitimized or institutionally supported.

6.2.2.2. *Contrasts.* For **APNs**, motivation was often driven by professional ambition and a desire to expand the scope of nursing practice. They described growing confidences over time as their teams began to recognize the clinical value they added. One APN remarked

> *“My legitimacy grew as my team recognized my role and expertise, providing strong support . . . But only as long as it didn’t disrupt routines.”*

**Peer-Helpers**, however, described a more fragile process of professionalization, often accompanied by self-doubt and ongoing negotiation of identity. Their lived experience, while central to their role, was also a source of stigma that made the transition particularly difficult. One Peer-Helper stated

> *“Balancing my mental health struggle with a new work environment was tough! Despite these challenges, I’ve now found clarity in my tasks and feel more grounded.”*

6.2.3. *Theme 3: “They Don’t Really Know What We Do”—Navigating Legitimacy in Team Contexts.* Both groups shared struggle in securing legitimacy within professional environments unfamiliar with their roles.

6.2.3.1. *Similarities.* Participants across both groups noted colleagues and supervisors frequently lacked a clear understanding of their responsibilities. The unfamiliar resulted in scepticism, exclusion from key decisions and repeated efforts to “prove” their value to the team. Legitimacy was not automatically conferred by formal title or training; it had to be negotiated in day-to-day interactions.

6.2.3.2. *Contrasts.* For **APNs**, resistance often took the form of professional boundary conflicts. Some team members viewed them as “super nurses,” overstepping into physician roles or diminishing the authority of traditional nursing staff. One APN reported

> *“There are misconceptions about what I do, leading to territorial conflicts and communication gaps.”*

**Peer-Helpers** described challenges strongly linked to stigma and role ambiguity. Their past experiences with mental illness often raised doubts about their reliability or stability, even among otherwise supportive colleagues. A Peer-Helper recounted

> *“There were unnecessary confrontations that led me to constantly justify my presence!”*

6.2.4. *Theme 4: “When Strategies Work”—Conditions for Collaborative Success.* Participants reflected on what enables or hinders collaboration within multidisciplinary teams, insights that form the foundation of our fourth theme. Their accounts revealed how APNs and Peer-Helpers navigate structural and interpersonal factors that shape partnerships, with particular attention to moments when collaborative strategies proved effective.

6.2.4.1. *Similarities.* When collaboration functioned well, participants reported improved communication, care coordination and service-user engagement. However, this success was often conditional, dependent on team openness, clearly defined roles and mutual respect. Where these conditions were absent, collaboration either stalled or regressed.

6.2.4.2. *Contrasts.* **APNs** were more likely to report that collaboration improved over time as colleagues gained familiarity with their scope of practice. They emphasized active communication as a pathway to trust-building. One APN noted

> *“Patient care is not compromised. On the contrary, collaboration with other healthcare professionals improves care coordination and adds value to patient support.”*

**Peer-Helpers** had more mixed experiences. While some felt integrated, many reported that doubts about their role persisted, particularly in teams unfamiliar with peer support models. One Peer-Helper commented

> *“My focus is on empowering patients, but differing perceptions within the team affect my practice and risk management strategies.”*

In multiple documented cases, unresolved tensions led Peer-Helpers to leave their positions, exposing how unsupported collaboration undermines role sustainability.

6.3. *Summary of Findings.* This study reveals how APNs and Peer-Helpers construct their professional roles and navigate integration within French mental healthcare teams. While APNs were more likely to experience growing recognition overtime, often enabled by their clinical expertise and alignment with biomedical hierarchies, Peer-Helpers faced more fragile trajectories. Despite receiving training and institutional endorsement, several Peer-Helpers in this study had resigned from their roles due to persistent stigma, unclear expectations and lack of recognition from colleagues. These patterns already expose early signs of “tension” between emerging and established professions.

Such findings suggest that professional integration is not guaranteed by credentials alone but must be continually negotiated through team culture and everyday interaction. Notably, the emotional and professional burden of proving legitimacy fell more heavily on Peer-Helpers, highlighting the relational precarity of roles grounded in lived experience.
This dynamic holds significant implications and has in-
ternational relevance for health systems seeking to formalize
innovative practice and peer work without adequately
addressing cultural and relational dimensions of team
inclusion.

7. Discussion

7.1. *Legitimacy Beyond Integration: The Struggle of Emerging Roles.* The integration of APNs and Peer-Helpers into France's psychiatric services is typically framed in policy discourse as a structural innovation: the pragmatic “addi- tion” of new roles to fill workforce gaps or enhance recovery- oriented care. However, our findings uncover a more complex and conflictual field reality: an ongoing negotiation of legitimacy, identity and knowledge within entrenched professional hierarchies. Integration, in this light, is not simply about technical coordination or organizational re- form, but about who is recognized as credible, whose knowledge is authorized and what counts as care.

This data interpretation reframes an ongoing socio-
professional struggle. We draw on four intersecting lenses to
make sense of this dynamic: (1) contested professional
boundaries, (2) epistemic injustice, (3) hybridization versus
sedimentation of roles and (4) the performative limits of
managerial change. Together they reveal how symbolic in-
clusion of new roles often masks deeper resistance to redis-
tributing power and knowledge within mental healthcare.

7.2. *Jurisdictional Boundaries: Who Am I?* Across interviews, participants described recurring tensions around their roles, legitimacy and recognition. APNs spoke of being caught between professions, *"too medical for nurses, not medical enough for doctors,"* while Peer-Helpers reported struggling to justify their presence in clinical spaces: *"There were unnecessary confrontations that led me to constantly justify my presence!"*

These dynamics reveal more than individual discomfort;
they expose how new roles unsettle professional boundaries
and established hierarchies. APNs, with their prescriptive
authority and expanded clinical tasks, encroach on medical
domains while Peer-Helpers, drawing on experiential
knowledge, disrupt the conventional divide between patient
and professional. However, their presence remains pre-
carious: tolerated as long as it does not destabilize existing
power configurations.

These dynamics reflect what Abbott [34] describes as
*jurisdictional conflict*, which conceptualizes professional
struggle over legitimacy and task control, and what Gieryn
[35] terms *boundary work*, or the discursive efforts to define
and defend professional knowledge. In our data, “in-
tegration” often appears more as a precarious accommo-
dation than genuine transformation, a symbolic inclusion
without structural change.

7.3. *Affective Labour: We Are Pioneers!* While existing literature often emphasizes the cognitive or procedural aspects of professional integration, our findings highlight a less

visible but essential dimensions: *affective labour*, as con-
ceptualized by Hochschild [36]; referring to the emotional
work required to meet institutional expectations; and *liminal
labour*, described by Turner [37], which captures the un-
certainty and vulnerability inherent in transitional and
ambiguous professional roles. Results confirm APNs and
Peer-Helpers invest substantial emotional energy to manage
ambiguity, scepticism and institutional resistance.

They are often cast as “pioneers,” expected to legitimize
their own roles through performance and resilience. As one
Peer-Helper noted, “*We carry the burden of proving that we
belong.*” This is not simply about adaptation; it is about
holding the emotional weight of institutional change
without systemic support.

The liminal “in-between” status of these actors makes
their presence both vital and vulnerable. They occupy
emerging and transitional spaces between professions,
policies and paradigms, a role that is transformative but also
exhausting. The absence for this labour renders systemic
change incomplete and personally costly.

7.4. *Epistemic Injustice: They Don't Know What We Do?!* Despite formal inclusion, APNs and Peer-Helpers often remained excluded from key decisions and knowledge production. This marginalization reflects what Fricker [38] theorizes as *epistemic injustice*, a form of exclusion that delegitimizes certain kinds of knowledge and undermines the authority of those who hold it.

Peer-Helpers experience *testimonial injustice*: their ex-
periential expertise is often dismissed as anecdotal, emo-
tional or tokenistic. Their narratives may be welcomed in
institutional symbolic agendas but excluded from clinical
deliberations. APNs, on the other hand, face *hermeneutic
injustice*, and their clinical observations are undervalued in
physician-dominated environments, where interpretative
and prescriptive frameworks remain firmly biomedical.

Across interviews, we encountered recurring experiences of epistemic silencing: "They don't understand what we do," or "Our input is not seen as real expertise," and "Non-Scientific." The paradox is thought-provoking: these roles are integrated structurally but excluded epistemically. Without redistributing epistemic authority, recovery-oriented reforms risk reinforcing existing hierarchies rather than transforming them.

7.5. *Hybridization vs. Sedimentation: When Strategies Work (or Don't).* Although both APNs and Peer-Helpers stem from international innovations, their implementation in France is shaped by local institutional logics. Rather than being simply adopted, these roles are reconfigured, often not through *hybridization*, where new forms emerge through negotiated integration [39]. However, through *sedimentation*, where innovation collapses into familiar patterns and loses its disruptive potential [40]. For instance, evidence confirms APNs reverted to routine nursing tasks during understaffing while Peer-Helpers were confined to symbolic presence or reduced to “feel-good” storytelling.
These patterns illustrate what Callon [41] describes as *institutional translation*, where roles mutate to fit existing power dynamics. Without intentional boundary renegotiation and shared institutional learning, we reform risks producing “zombie roles”: new titles, old routines.

7.6. *Why Change Models Fail?* Classic change models (e.g., [42, 43]) offer a rational and linear view of innovation: unfreeze, change and freeze. Yet, in the mental health settings we studied, change rarely followed such a path. It was experienced as political, emotional and, in many cases, conflictual; not due to poor planning, but because they *threaten jurisdictional claims* [34], *disrupt epistemic hierarchies* [38] and *destabilize professional identities* [37]. As one APN put it “*We were encouraged to innovate, as long as we didn't disrupt routines.*”

Our data show that change did not stem from policies or frame works but from relational efforts on the ground, from APNs building legitimacy through sustained clinical contribution and from Peer-Helpers asserting experiential expertise in spaces where lived knowledge was routinely disqualified. These tensions were not anomalies, but key sites of slow, situated transformation. They confirm what contemporary complexity theorists [44, 45] have argued: meaningful change is emergent, nonlinear and driven by friction.

Even progressive frameworks like WHO-Europe's [46] roadmap risks overlook this reality when they frame integration as a technical toolkit, rather than as a political and epistemic struggles. In our study, all tangible shifts emerged not from consensus, but from persistence within ambiguity. Without confronting embedded asymmetries, new roles remain symbolic gestures rather than structural levers. Reform, in this light, is less about implementation than about negotiating epistemic justice, emotional labour and professional sovereignty.

## 8. Conclusion: From Inclusion to Redistribution

The data revealed a process of professional integration that exposes the structural tensions within France's system. The introduction of APNs and Peer-Helpers involves reconfigurations of care, professional legitimacy and the value attributed to experiential knowledge. Transformation does not unfold through formal frameworks, but through relational processes marked by uncertainty, affect and negotiation. It is within these zones of friction that subtle yet tangible shifts in established hierarchies begin to take shape.

## 9. Strengths, Limitations and Implications

This study offers a rare, comparative qualitative inquiry into two emerging professional identities, APNs and Peer-Helpers, within France's structured mental healthcare system. Its strength lies in centring the lived experience of these actors, whose voices are often instrumentalized yet rarely studied side by side. By triangulating data and drawing on

analytical tools from the sociology of professions, we foreground integration not as a policy goal but as a site of ongoing struggle over legitimacy and knowledge.

The focus on pioneers and early adopters may limit the transferability of findings to more institutionalized contexts or late-stage implementations. Moreover, while the small sample enabled deep qualitative analysis, it reflects a partial view that should be expanded through future multisite and ethnographic research.

Clinically, the findings invite a rethinking of professional “integration” not as a role coordination but as a cultural and epistemic redistribution. The persistent misrecognition of experiential and nursing knowledge reveals a system shaped by rigid professional sovereignies.

What we observe in France echoes a wider international pattern: the symbolic incorporation of new roles without meaningful redistribution of authority. Rather than signalling progress, such forms of integration may reproduce that very hierarchies they claim to reform.

The French case is not isolated. Across mental health systems, emerging roles are often absorbed without shifting the foundations of professional power. When integration avoids redistributing legitimacy and voice, it risks reinforcing the status quo under the guise of innovation.

## Data Availability Statement

Data are not publicly available due to ethical and privacy restrictions. Access to anonymized excerpts may be granted by the corresponding author upon reasonable request and subject to institutional approval.

## Ethics Statement

The study is registered at the Data Protection Unit of the French *Centre National de la Recherche Scientifique* (CNRS). It obtained approval from the Research Ethics Committee of the University of Paris on March 23, 2023 (No 2023-6-DE JESUS-MORGIEVE, No IRB: 00012023-6).

## Disclosure

Although this study received funding from INSERM Cermes3 laboratory, the funding body had no role in the study design, data collection, analysis or decision to publish. A preliminary version of this work was presented as an oral communication at Horatio 2024 -European Psychiatric Nursing Congress and was subsequently selected within the European Commission Best and Promising Practices of 2024.

## Conflicts of Interest

Nancy De Jesus is co-chair of the WHO Strategic Partners' Initiative for Data and Digital Health (SPI-DDH) Public Health Working Group and an active member of the WHO/ Europe Pan-European Mental Health Coalition. The authors declare no conflicts of interest.
## Author Contributions

Nancy De Jesus and Margot Morgiève made substantial contributions to conception and design, or acquisition of data or analysis and interpretation of data; Nancy De Jesus and Margot Morgiève involved in drafting the manuscript or revising it critically for important intellectual content; Nancy De Jesus, Damien Croguennec and Margot Morgiève gave final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; Nancy De Jesus, Damien Croguennec and Margot Morgiève agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

## Funding

This study was supported by the Institut National de la Santé et de la Recherche Médicale (INSERM) Cermes3 laboratory for the proofreading and publication fees.

## Acknowledgments

We extend our heartfelt gratitude to all the participants who generously shared their experiences, perspectives, and invaluable insights, which contributed to the success of this research. The authors would like to thank the Cermes3 laboratory and to Mr. Jude Sweeney. Finally, we acknowledge Pole 94G16 network of Paris Est Val-de-Marne Hospitals and all the professionals who collaborated in this study.

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