Take the Self-Survey

The SHUNT Self-Survey For Nurses™ Scoring Sheet
Copyright © 2008-2017 Paula Davies Scimeca, RN, MS
All Rights Reserved, except as specified below.
www.unbecominganurse.org
email: paula@unbecominganurse.org

The author gives permission for this scoring sheet to be copied only when the following conditions are met: it is done solely for a nurse's own personal use; the author and publisher are held harmless from any and all liability; and any and all copies prominently display this copyright information and the following disclaimer: This tool is not intended to diagnose chemical dependency, or any other situation or condition. No score indicates a total absence of risk, nor any certainty that anyone is, or ever will become, chemically dependent.
For more specific information regarding scoring criteria, please refer to the book: Unbecoming A Nurse.

Score each characteristic below with 1 point for YES or zero for NO.

S - Social withdrawal or self-isolative behavior. ____________
Self-care behaviors beneath societal, professional societal, professional ____________
History of chemical dependency in the nurse’s immediate family. ____________
H - History of negative consequences related to the nurse's substance use. ____________
U - Untreated or unremitting emotional or physical pain. ____________
U - Using medication for a reason it was not intended or in a manner not recommended. ____________
N - Nursing practice routinely in excess of 55 hours per week. ____________
N - Nursing duties include frequent access to controlled substances. ____________
T - Transitional period requiring major adjustment within the past year. ____________
T - Turmoil or tragedy with unresolved conflict. ____________

DATE:________________________

TOTAL= ____________