School Nurses' Perceptions of Mental Health Responsibilities Within School Nursing Practice: A Q Methodology Study

BACKGROUND: School nurses frequently encounter student mental health concerns, but little is known about how they prioritize mental health responsibilities relative to other nursing duties and local team structures. METHODS: This Q methodology study examined shared viewpoints about school nurse duties that most support positive student and school outcomes. Seventy nurses from six rural, high-poverty US school districts ranked 25 duties aligned with the National Association of School Nurses framework. Q sorts were analyzed using centroid extraction and Varimax rotation; post-sort comments informed viewpoint interpretation. RESULTS: A three-viewpoint solution explained 71% of the variance, with 52 nurses loading significantly. Viewpoint 1 prioritized suicide-risk response and mental health work as safety responsibilities. Viewpoint 2 emphasized medical expertise and crisis-oriented mental health involvement. Viewpoint 3 prioritized planning and care coordination while ranking direct mental health duties lower. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Findings support clear role expectations, aligned referral and crisis protocols, appropriate staffing, and targeted professional learning for school nurse participation in mental health teams. CONCLUSIONS: Nurses agreed on core safety duties but differed in how mental health responsibilities fit within routine school nursing practice.