Take the Self-Survey

The SHUNT Self-Survey For Nurses™ Scoring Sheet

Copyright © 2008 Paula Davies Scimeca, RN, MS        All Rights Reserved

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 disclaimer and the copyright information. This tool has not met the strict criteria of a scientific study; nor is it intended to diagnose chemical dependency, or any other situation or condition. For scoring criteria, refer to the book: Unbecoming A Nurse.

No score indicates a total absence of risk, nor any certainty that anyone is, or ever will become, chemically dependent.

YES = 1 NO = 0

S - Social withdrawal or self-isolative behavior.

 ____________

S - Self-care behaviors beneath societal, professional or the nurse's own standards.

____________

H - 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= ____________