Evaluating Professional Misconduct: The Effects of Licensure State and Board Membership

Abstract

Purpose: By further analysis of a subset of data collected from licensed social workers from six selected states, this article explores the effect of respondents’ licensure state and board membership on their perceptions of professional misconduct vignettes. Methods: Using a simplified factorial survey design, 5,388 licensed social workers evaluated versions of vignettes involving social worker misconduct. Respondents rated the vignettes as serious and important to discipline and assigned sanctions to the vignette they viewed as most troubling. The licensure state was a factor in the seriousness and importance of discipline ratings, board membership less so. Results: Results indicated that some factors involved in misconduct are more relevant than others. Respondents generally agreed on the most troubling vignettes and sanctions appropriate to the action. Conclusions: These results may serve as preliminary support for the formation of national licensure standards and processes.

Keywords

social work regulation licensing sanctions factorial survey

Regulating the practice of physicians, nurses, social workers, and other professionals in the United States is a basic obligation in providing human services (Grise-Owens et al., 2016; Wiles, 2011). Since the 1960s, licensing for social workers gained traction, and now every U.S. state and territory and the District of Columbia require social workers to be licensed at the clinical level, though many jurisdictions require licensure at the master's and bachelor's levels as well (Donaldson et al., 2014; Garcia, 1990; Grise-Owens et al., 2016). While the Association of Social Work Boards (ASWB) provides some guidance to licensing entities in the form of the Model Social Work Practice Act (2018), each licensing board decides its own requirements for licensure and determines the makeup of its board membership.

Definitions for training, supervision, and continuing education for social workers and even how to define “social work” vary across boards (Boland-Prom et al., 2018; Donaldson et al., 2014; Hill et al., 2017). In some places, bachelor's level social work licenses are available; in others, licensure begins only at the master's level (ASWB, 2022). The number of hours of supervised practice post-MSW is 1,500 hours in Florida, 3,000 hours in Ohio and Rhode Island, 3,500 hours in Oregon, and 4,000 hours in Minnesota and Oklahoma (ASWB, 2022). Continuing education requirements are as few as nine hours each year for full-time bachelor's level licensees in Tennessee and as many as 48 hours in a two-year period in Alaska for all licensure levels (ASWB, 2022). Every social work board must have at least one social worker licensed at the clinical level as a member; however, the makeup of the remaining members may include other individuals outside of the profession, such as community members, attorneys, or physicians (ASWB, 2022; Donaldson et al., 2014). Most social work licensing boards include only those licensed as social workers, though others include disciplines such as marriage and family therapists, professional counselors, and addiction professionals as well (ASWB, 2022; Garcia, 1990).

What is regulated from state to state also varies. To illustrate differences, this literature review uses the same practice example: a social work supervisor engaging in a sexual relationship with a supervisee. Some areas rely on the National Association of Social Workers’ (NASW) Code of Ethics (2021) to guide the expectations of social work practice, as is the case in Rhode Island. Others write into law more specific guidance. While the NASW Code of Ethics Standard 2.06 states that “supervisors should not engage in sexual activities… with supervisees, students, trainees,” Minnesota regulations heighten the expectation to “must not engage in [such activities] …” (emphasis added) (Minnesota Board of Social Work Practice, 2021). Ohio’s statutes related to sexual relationships are housed within a Code of Ethics of professional conduct that applies to counselors, social workers, and marriage and family therapists in that state, but there is no mention of sexual relationships between supervisors and supervisees (Ohio Counselor, Social Worker, & Marriage and Family Therapist Board, 2021). Florida's regulations include a similar population and use similar language (Florida Clinical, Counseling, and Psychotherapy Services, 2021).

This comparison focuses on one practice example and its interpretation across six states; however, social workers in the United States must consider many interpretations in licensing and regulation when practicing in different states or territories (Donaldson et al., 2014). Social workers have expressed confusion about what constitutes professional conduct (Jayaratne et al., 1997) and often disagree on what actions to take in practice situations (Mattison, 2000). One's background and personal beliefs can also influence professional decision-making (Mattison, 2000). This article reports a new analysis of data collected in a previous study (Gricus & Wysiekierski, 2022). This article aims to focus on the possible influence of the respondents’ licensure state and whether they had served on their state's social work licensing board on their perceptions of professional misconduct.

Literature Review

Perceptions of Social Work Regulation

Published research about social workers’ perceptions of social work regulations is minimal, despite regulation being a part of professional social work since 1934 (Corcoran & Roberts, 2016). In their 2011 book on licensing practices, Bibus and Boutté-Queen (2011) reported that “there are fewer published articles [on licensing] than expected” (p. 11), and more than a decade later, these authors can make a similar assertion. Recent studies on social work licensing boards have centered on perceptions within social work education (Boland-Prom et al., 2018; GlenMaye & Bolin, 2015; Miller et al., 2017) or licensees’ experiences with the disciplinary action process (Barsky et al., 2021; Gricus, 2018).

Some have criticized social work licensing boards for overreach by focusing too much on creating a single image of who a social worker is and what a social worker does, creating an unnecessary fear of liability or sanctioning (Floyd & Rhodes, 2011). This fear can create an environment of “over-vigilance” (Gunther, 2014). Magiste (2020) describes the “who, how, and what” of regulation as “an essential professional conversation that needs to continue” (p. 757).

Professional Accountability

Licensing boards protect the public, in part, by adjudicating complaints of licensees’ unprofessional and/or unethical behavior (ASWB, Model Social Work Practice Act, 2018). When a licensee is found to have violated professional standards, the board assigns one or more consequences, which can include public acknowledgment of the licensee's actions on the board's website, required continuing education, fines, and, in some cases, suspension or revocation of a license (ASWB Model Practice Act, 2018; Boland-Prom et al., 2015; Davis, 2020; Magiste, 2020; Strom-Gottfried, 2000). Often, the state's licensing board collects, records, and reports this information at the local level and sometimes makes it available to the public; however, some social workers in certain clinical settings have information about their violations and sanctions reported to the National Practitioner Data Bank (U.S. Department of Health and Human Services, n.d.).

The Model Social Work Practice Act identifies the types of sanctions but does not match sanctions with types of violations, creating differences from state to state (ASWB, 2018). Boland-Prom et al. (2015) reviewed the complaints reported to the ASWB between 2000 and 2009. Through a review of the raw dataset, obtained from Dr. Boland-Prom in 2019, the author found differences in sanctioning for similar violations across states. For example, penalties for noncompliance with continuing education (and no additional violation) typically involved fines; however, reported fines ranged from $100 to $1500, depending on the state in which the noncompliance occurred.

The dataset included eight supervisors in seven states who allegedly engaged in sexual intercourse with a supervisee or a student intern, and the consequences also varied considerably (Boland-Prom, 2009a). Two were denied licensure in the application phase or had a license permanently revoked, two were mandated to complete additional continuing education, one was fined $1,000 plus 1 year of supervised practice, and the remaining supervisors received more than two penalties. For instance, a male-identified supervisor licensed in the Northeast received a written reprimand, had his license suspended for up to a year, and was required to complete three years of supervised practice. Conversely, the dataset included one female-identified supervisor in this category, licensed in the Southwest, was penalized with 2 years of probation, 2 years of supervised practice, a mental health evaluation, and more than 50 h of community service (Boland-Prom, 2009a). The dataset did not include information about race and ethnicity.

Across complaints, Boland-Prom (2009b) found a “wide discrepancy” (p. 353) among states in the number of violations adjudicated by licensing boards, and states have “unique patterns related to the types of offenses that received attention” (p. 359). In his more recent doctoral dissertation, Davis (2020) reviewed clinical social worker cases reported to the National Practitioner Data Bank and found that the number of practice hours a state required to become licensed as a clinical social worker was directly related to the number of sanctions assigned to practice violations—the more hours, the more penalties. The analysis reported here examines whether these patterns of difference exist across a set of vignettes based on real professional misconduct cases of social workers across licensure levels.

Methods

Participants

The Institutional Review Board of Hood College (#1819-25) approved this study. All participants consented electronically before starting the survey. In July 2019, the author's research assistant (an undergraduate social work student) emailed all active licensed social workers in six states—Florida, Minnesota, Ohio, Oklahoma, Oregon, and Rhode Island, for a total of 56,131 possible respondents. The budget for this study was the dominant factor in this selection of states, as their email lists were more affordable than others. After excluding email bounce-backs and survey opt-out messages, 54,155 invitations went out. The survey was available for four weeks. Participants were eligible to win one of two gift cards by providing an email address after the survey.

Study Design

This study incorporated vignettes in a simplified factorial survey to determine variables involved in evaluating social workers’ beliefs about unprofessional behavior. Vignettes based on real people and situations provide opportunities to get an impression of the factors influencing study participants’ decision-making processes (Evans et al., 2015). These vignettes consisted of anonymized cases from licensing board websites that matched the eight categories of violations cited by Boland-Prom et al. (2009b) and used similar patterns of information (Atzmüller & Steiner, 2010). The format included level of licensure, length of time in practice (when known), official allegation, and individual's reaction to the allegation (when known). To maintain respondents’ interest in evaluating vignettes (Hughes & Huby, 2004), the eight vignettes were randomized and then separated into two surveys (Atzmüller & Steiner, 2010), each survey including four vignettes. The survey software randomized the order of the four vignettes included in each survey.

As previously mentioned, the study was designed as a simplified factorial survey, in which one variable in each vignette was changed (Ganong & Coleman, 2006). Three of the vignettes’ variables were based on the perceived personal characteristics of the social worker: gender, race, and sexual orientation. For example, the name and pronouns of the social worker involved in the vignette changed, but all other details stayed the same. In all other vignettes, the variable was related to the details of the situation. In the vignette about an impaired provider, one version referenced methamphetamine use and the other, alcohol. See Table 1 for vignette versions. The survey software randomly assigned respondents to the different versions of the vignettes, unbeknownst to the respondents. The Journal of Social Work published the results of the effects of changed variables on all respondents’ interpretations of the vignette (Gricus & Wysiekierski, 2022). This article focuses on a narrower group of respondents: those who indicated that they were current or former board members, and those that did not (labeled as “non-board members” going forward).

Table 1.
Survey vignettes with changed variable.

Category of Violation^a Survey 1 (Version 1)^b Survey 1 (Version 2)^b Changed Variable

Dual relationships Kathleen has been a licensed social worker at the bachelor's level for nine years. Kathleen claims that she and Anne, an elderly client, were friends that Anne offered to loan her over $2400. Kathleen has indicated that she plans on repaying Anne the money she borrowed per a contracted agreement. However, Kathleen has not yet begun making the payments. Kathleen has been a licensed social worker at the bachelor's level for nine years. Anne, an elderly client, reports that she agreed to lend Kathleen over $2400. Kathleen has indicated that she plans on repaying Anne the money she borrowed per a contracted agreement. However, Kathleen has not yet begun making the payments. Viewpoint of the relationship

Crimes Michael has been a licensed clinical social worker for over 25 years. He was convicted of 10 counts of Medicaid fraud and served time in jail. Michael reports he was innocent and that he was taken advantage of, claiming that he is “computer illiterate” and relied on someone else to type his notes and file the claims. Michael has been a licensed clinical social worker for over 25 years. He was accused of 10 counts of Medicaid fraud and served time in jail. Michael reports he was innocent and that he was taken advantage of, claiming that he is “computer illiterate” and relied on someone else to type his notes and file the claims. Conviction versus accusation

Below standards of care Trevor received his MSW 4 years ago and his clinical license 2 years ago. He works at a therapeutic day school for kids with emotional and behavioral challenges. A colleague filed a complaint with the licensing board that Trevor did not notify his supervisors of a reportable incident: A minor female client said she had been physically threatened by a minor male client and was fearful for her safety. Trevor admitted he failed to report and document the incident. Trevor received his MSW 4 years ago and his clinical license 2 years ago. He works at a therapeutic day school for kids with emotional and behavioral challenges. A colleague filed a complaint with the licensing board that Trevor did not notify his supervisors of a reportable incident: A minor male client said he had been physically threatened by a minor female client and was fearful for his safety. Trevor admitted he failed to report and document the incident. Gender of clients involved

License-related Erick received his MSW degree five years ago and has been employed in a social work role. He has not taken steps to become licensed. The state law where Erick lives requires MSW graduates to obtain a license within 6 months of practicing. Erick received his MSW degree seven months ago and has been employed in a social work role. He has not taken steps to become licensed. The state law where Erick lives requires MSW graduates to obtain a license within 6 months of practicing. Length of time involved

Category of Violation^a Survey 2 (Version 1)^b Survey 2 (Version 2)^b Changed Variable

Poor basic practice Jennifer has been a licensed social worker at the bachelor's level for less than 2 years. The [licensing] board received a complaint from Jennifer's employer that Jennifer has not conducted home visits or services she claimed to have provided to at least one client. The client, Crystal, said she had seen not Jennifer for these visits and did not recognize the signature as her own on signed documents. Jennifer allegedly asked Crystal to lie saying that they saw one another. She promised Crystal that her child protection case could be closed sooner if she went along with it. John has been a licensed social worker at the bachelor's level for less than 2 years. The [licensing] board received a complaint from John's employer that John has not conducted home visits or services he claimed to have provided to at least one client. The client, Crystal, said she had not seen John for these visits and did not recognize the signature as her own on signed documents. John allegedly asked Crystal to lie saying that they saw one another. He promised Crystal that her child protection case could be closed sooner if she went along with it. Gender of social worker

Supervision below the standards of care Roger has been a clinical social worker for 10 years and is a field instructor for students in their internships. He allegedly engaged in sexual activity with one of his current female students. Roger has been a clinical social worker for 10 years and is a field instructor for students in their internships. He allegedly engaged in sexual activity with one of his current male students. Perceived sexual orientation of social worker

Billing Lindsey has had her LMSW (nonclinical, master's level) license for 10 years. She was accused of submitting incomplete and late assessments and progress notes. While investigating these accusations, Lindsey's employer located billed services that did not occur. Lindsey resigned from her position and decided to not continue as a practicing social worker. La-Teesha has had her LMSW (nonclinical, master's level) license for 10 years. She was accused of submitting incomplete and late assessments and progress notes. While investigating these accusations, La-Teesha's employer located billed services that did not occur. La-Teesha resigned from her position and decided to not continue as a practicing social worker. Perceived race of social worker

Impaired social worker Sam has her clinical license and works as an alcohol and drug abuse counselor. Sam has an active addiction to methamphetamine. This has resulted in her being out of work sick often and affecting her while she is at work. Sam has her clinical license and works as an alcohol and drug abuse counselor. Sam has an active addiction to alcohol. This has resulted in her being out of work sick often and affecting her while she is at work. Type of substance

^a
Boland-Prom (2009b).

^b
Emphasis added.

In this study, respondents became the “disciplinary decision-maker” (Salvador, 2019) by answering questions about the vignettes. Questions included: “How serious is this incident in your opinion?” and “How important is it for the licensing board to discipline this social worker?” Respondents selected an answer from a 0–7 Likert scale of seriousness and importance, respectively. After reviewing all assigned vignettes, respondents then indicated which they believed was the most troubling.

Data Analysis

All data analysis for this study was performed through SPSS, Version 27. Since respondents provided their ratings for the dependent variables (i.e., seriousness, importance to discipline) on a 0–7 Likert scale, the data were at the scale level of measurement (de Winter & Dodou, 2010). However, because of an uneven distribution of the responses, the Likert responses were collapsed into three categories and the data were treated as polychotomous (categorical) (Haq & Nazir, 2016).

Chi-square tests of independence (X²) determined whether respondents’ ratings of seriousness and importance to discipline were related to status as a board member or state of licensure. Chi-square allows for unequal distributions among independent categorical variables in a large sample, the best approach for this type of data (Haq & Nazir, 2016; Wu & Qiu, 2021). Statistics where p < .05 are reported. Because chi-square tables were greater than 2 × 2 across the analysis, the Cramer's V calculation determined the effect size (Wu & Qiu, 2021). The effect sizes used to determine the strength of the relationship between groups are based on Rea and Parker’s (2014) table: negligible association (.00 and under .10), weak association (.10 and under .20), moderate association (.20 and under .40), relatively strong to a very strong association (.40 –1.00).

Results

The analysis included only those surveys with 80% of questions answered, including at least one demographic question. After filtering incomplete surveys and respondents who were not currently licensed, and those who did not answer the question “Are you now or have you ever been a member of a licensing board?” 5,388 surveys remained, representing an overall response rate of 9.9%. Participants were randomly assigned to a version of the survey, with 50.1% (n = 2,470) of nonboard members and 55.2% (n = 253) of board members completing Survey 1, and the remaining respondents completing Survey 2. Demographic data were separated for board members and nonboard members.

Characteristics of the Respondents

Most nonboard member respondents (71.9%; n = 3,545) indicated their primary positions were in direct service roles, and 15.2% (n = 15.2%) reported indirect social work practice (e.g., advocacy, policy, research, administration, management, supervisory). Nearly 93% of these respondents reported current employment, with 70.1% (n = 3,454) working 40 or more hours per week and 21.4% (n = 1,053) working 1–39 h per week. Current or former licensing board members’ demographics are similar. The overall sample was overwhelmingly represented as white, female, and heterosexual. See Table 2 for additional demographic information. Results are organized by survey type.

Table 2.
Respondent demographics.

Characteristic (n = 5,388) Nonboard Member(n = 4,930) Board Member(n = 458)

n % n %

Age

21–32 774 15.7 69 15.1

33–39 733 14.9 80 17.5

40–49 896 18.2 93 20.3

50–59 892 18.1 85 18.6

60 + 947 19.2 66 14.4

Did not provide 688 14.0 65 14.2

Length of practice

< 15 years 2,470 50.1 247 53.9

15 + years 2,451 49.7 211 46.1

Did not provide 10 0.3 0 0.0

State

Florida 818 16.6 42 9.2

Minnesota 1,458 29.6 153 33.4

Ohio 2,110 42.8 213 46.5

Oklahoma 227 4.6 34 7.4

Oregon 214 4.3 14 3.1

Rhode Island 103 2.1 2 0.4

Practice setting

Private organization/nonprofit social services 877 17.8 73 15.9

Community mental health/substance use agency 557 11.3 63 13.8

Hospital/medical clinic 781 15.8 63 13.8

School/other youth-serving organization 331 6.7 35 7.6

Federal/state/local government (including child welfare, DHS, VA) 671 13.6 71 15.5

Private practice/self-employed 533 10.8 42 9.2

Other (corrections, higher ed., for-profit 896 18.2 92 20.1

Did not provide 285 5.8 18 4.1

License level

Bachelor's level (e.g., BSW, LSW, LBSW) 1,123 22.8 137 29.9

Master's level, not independent (e.g., CSW, LMSW, LGSW) 801 16.2 86 18.8

Master's level, independent, nonclinical (e.g., CSW, LISW) 420 8.5 36 7.9

Master's level, independent, clinical (e.g., LCSW, LCSW-C, LICSW) 2,556 51.9 195 42.6

Other 21 0.4 4 0.9

Did not provide 9 0.01 0 0.0

Survey 1 Vignettes and Factors

When respondents assessed the version of the survey in which Michael is accused but not convicted of fraud, board members and nonboard members rated the importance to discipline differently (X² [2, n = 2,688] = 8.546, p = .014). Board members were more likely to rate the case as “important” than nonboard members, though the effect size was negligible at 0.081. The other version, in which Michael is convicted, resulted in statistically significant differences in ratings of seriousness among respondents licensed in different states (X² [10, n = 2,760] = 27.126, p = .002). This difference had a negligible effect (0.059). Licensure state was a statistically significant factor correlated with the seriousness of the conduct in the vignette as rated by the respondent (X² [10, n = 2,760] = 20.809, p = .022) in both versions of the survey, but that difference had a negligible effect (0.061).

When assessing Trevor's failure to report a male threatening a female client, the vignette included as an example of “below standards of care,” board members were more likely to select “not serious” or “serious” than nonboard members (X² [2, n = 2,661] = 7.562, p = .023), a negligible effect of 0.074. When the clients’ genders were reversed, respondents from Oregon were more likely to select “not important” and Minnesota as “important” than the other four states (X² [10, n = 2,642] = 28.575, p = .001), with negligible effect (0.011). Overall, there was a statistically significant difference between ratings of importance to discipline across vignettes (X² [10, n = 2,642] = 34.940, p = <.001), a negligible effect of 0.081, with licensees from different states rating an unreported incident between a male threatening a female higher than the reverse.

One's involvement as a board member did not influence ratings for the seriousness or importance to discipline with either version of Erick's vignette. Statistical significance was noted across versions and seriousness and importance to discipline: Three-quarters of respondents in Ohio (n = 456, 76.1%) and Oklahoma (n = 53, 75.6%) deemed Erick's practicing without a license for 5 years as “very serious,” while only 56.0% (n = 14) of those in Rhode Island did (X² [10, n = 2,689] = 34.726, p = <.001), a weak effect of 0.113. When the length of practice in the vignette was 7 months, two-thirds of Ohio (n = 388, 67.2%) and Oklahoma (n = 48, 66.7%) respondents identified the infraction as very serious compared to 47.2% (n = 25) among Oregon respondents (X² [10, n = 2,689] = 40.604, p = <.001), a weak effect of 0.124. Whether Erick's situation was important to enact disciplinary measures was also a statistically significant factor for respondents licensed in different states for practicing without a license for 5 years (X² [10, n = 2,646] = 50.145, p = <.001, effect size weak at 0.136) and 7 months (X² [10, n = 2,646] = 51.675, p = <.001), with a weak effect of 0.141. A relationship between licensure states was found between vignette ratings related to seriousness (X² [10, n = 2,689] = 68.331, p = <.001) and importance to discipline (X² [10, n = 2,646] = 90.503, p = <.001), though with a weak effect in both (0.113, 0.131). The longer the time without a license, the more respondents licensed in different states perceived the situation as serious and subject to disciplinary measures. See Tables 3 and 4 for frequencies across Erick's vignette. Neither version nor variable in Kathleen's vignette resulted in statistical significance.

Table 3.
Frequency table, erick vignette, seriousness.

Not Serious Serious Very Serious

Variable Board Status n % n % n %

Unchanged factor Nonboard 109 90.1 260 92.2 855 91.2

Board 12 9.9 22 7.8 82 8.8

Changed factor Nonboard 147 88.0 327 92.6 692 89.4

Board 20 12.0 26 7.4 82 10.6

State

Unchanged factor Florida 27 22.3 60 21.3 129 13.8

Minnesota 45 37.2 89 31.6 254 27.1

Ohio 36 29.8 102 36.2 446 47.6

Oklahoma 2 1.7 15 5.3 53 5.7

Oregon 7 5.8 9 3.2 41 4.4

Rhode Island 4 3.3 7 2.5 14 1.5

Changed factor Florida 35 21.0 56 15.9 111 14.3

Minnesota 62 37.1 122 34.6 200 25.8

Ohio 53 31.7 130 36.8 379 49.0

Oklahoma 2 1.2 21 5.9 47 6.1

Oregon 12 7.2 16 4.5 25 3.2

Rhode Island 3 1.8 8 2.3 12 1.6

Table 4.
Frequency table, erick vignette, importance to discipline.

Not Important Important Very Important

n % n % n %

Variable Board status

Unchanged factor Nonboard 129 91.5 315 91.8 769 91.4

Board 12 8.5 28 8.2 72 8.6

Changed factor Nonboard 176 89.3 382 90.3 582 89.8

Board 21 10.7 41 9.7 66 10.2

State

Unchanged factor Florida 26 18.4 66 19.2 122 14.5

Minnesota 60 42.6 107 31.2 218 25.9

Ohio 34 24.1 133 38.8 409 48.6

Oklahoma 4 2.8 14 4.1 51 6.1

Oregon 11 7.8 14 4.1 30 3.6

Rhode Island 6 4.3 9 2.6 11 1.3

Changed factor Florida 37 18.8 59 13.9 97 15.0

Minnesota 81 41.1 140 33.1 156 24.1

Ohio 60 30.5 170 40.2 320 49.4

Oklahoma 4 2.0 24 5.7 43 6.6

Oregon 13 6.6 16 3.8 24 3.7

Rhode Island 2 1.0 14 3.3 8 1.2

Survey 2 Vignettes and Factors

Neither Jennifer/John nor Roger's vignettes resulted in statistical significance. In the two versions of the Lindsey/La-Teesha vignette, wherein improper billing practices were reported, respondents were expected to presume that the social worker in the first vignette, Lindsey, had a different racial identity than La-Teesha in the second version. Board members were more likely to identify Lindsey's vignette as “very important to discipline” capturing 86.0% (n = 86) of all responses, while 74.9% (n = 1,173) of nonboard members did the same (X² [2, n = 2,595] = 6.264, p = .044). The effect size of this difference is negligible at 0.070.

Respondents licensed in different states also perceived the importance of discipline as statistically significant, but for the version in which the social worker was perceived as a Black or African-American woman (X² [10, n = 2,632] = 22.666, p = .012), the effect size is negligible at 0.076. Respondents treated the vignette versions differently, rating La-Teesha as less serious and less important to discipline than Lindsey: seriousness (X² [10, n = 2,680] = 19.608, p = .033), with a negligible effect (0.060) and importance to discipline (X² [10, n = 2,632] = 26.967, p = .003), with a negligible effect at 0.072.

Sam's vignette presented an example of an impaired provider. When the vignette involved addiction to methamphetamine, board and nonboard members viewed the seriousness and importance of discipline similarly. The effect of respondents’ licensure state affected the ratings of importance to discipline for the methamphetamine version (X² [10, n = 2,601] = 26.538, p = .003), with a weak effect size of 0.100, but not for the alcohol one. Respondents in Minnesota (n = 279, 65.0%) and Rhode Island (n = 15, 65.2%) were less likely to rate the situation as “very important” to discipline than in the other four states.

Effect of Combined Variables

Independent variables—licensure state and board membership—were analyzed together to determine if board membership in a particular state influenced responses. Only results from Florida, Minnesota, and Ohio were included, based on sample sizes available for analysis.

Minnesota

Statistically significant differences were found between Minnesota board members and nonboard members. Board members considered Michael’s conviction as less important, selecting “important” when nonboard members selected “very important” 2.5 times more often (X² [2, n = 393] = 7.953, p = .019), with a weak effect of 0.142. Board members and nonboard members differed significantly in their ratings of seriousness when Trevor did not report a threat from a female to a male (X² [2, n = 396] = 10.496, p = .005), with a weak effect of 0.163. Minnesota board and nonboard members also differed in ratings of importance to discipline when Trevor did not report a threat from a male to a female (X² [2, n = 387] = 10.495, p = .005), with a weak effect of 0.165. In both cases, board members were more likely to select “not serious/not important” than nonboard members. Lastly, for Minnesota respondents who considered the seriousness of Erick’s 7 months without a license, board members selected “not important” twice as often as nonboard members (X² [2, n = 384] = 6.241, p = .044), though this difference has a weak effect (0.127).

Florida

Respondents in Florida viewed the seriousness of the alleged same-sex sexual relationship between Roger and a male student differently based on board membership (X² [1, n = 211] = 3.950, p = .047), but this difference was negligible (0.047). Florida Board and nonmembers also viewed the importance to discipline Sam's methamphetamine abuse differently (X² [2, n = 209] = 12.811, p = .002). Board members were more likely to view this situation as “not important to discipline” than nonboard members. This relationship is moderate (0.248).

Ohio

No statistically significant differences were found between board members and nonboard members in Ohio, except for Sam’s methamphetamine vignette. In contrast to the findings in Florida about the same vignette, Ohio board members (n = 40) selected “very important” in 95.2% of responses (X² [2, n = 563] = 7.760, p = .021), with a weak effect of 0.117.

Most Troubling

After rating their four vignettes, respondents considered the vignettes they found most and least troubling in their survey. For this analysis, Survey 1 and Survey 2 were separated, but the variables in the vignettes in each survey were analyzed together. In other words, the statistical analysis included Erick’s 7 months and 5 years without a license as one vignette, not two. Survey 1 respondents consistently selected the most troubling vignettes as Kathleen, then Trevor, Michael, and Erick, with no significant differences for board members and nonboard members. While there were similar patterns found in respondents licensed in different states, differences in distributions were significant (X² [15, n = 2,714] = 56.109, p = <.001), with a negligible effect of 0.083. Survey 2 board members’ and nonboard members’ responses were equally distributed among the most troubling vignettes, identifying Jennifer/John the most often followed by Roger, Lindsey/La-Teesha, and then Sam. Respondents licensed in different states made similar choices.

Recommended Sanctions

After reviewing their four vignettes and selecting the most troubling one, respondents assigned one or more sanctions. For the analysis, Kathleen’s (Survey 1) and Jennifer’s original vignettes (Survey 2) were isolated and the top three most frequently selected sanctions were reported. Board members and nonboard members alike recommended a variety of sanctions for Kathleen. Board members selected suspension (42.9%), continuing education (37.7%), and revocation (35.7%) more than all other sanctions. Nonboard members suggested suspension more often (51.2%), then supervised practice (38.3%), and continuing education (37.3%). Board members in Survey 2 suggested similar sanctions for Jennifer/John, with 52.6% supporting suspension, 36.8% recommending the supervised practice, and 34.7% recommending continuing education. Nonboard members recommended suspension (51.5%), supervised practice (40.9%), and revocation (34.9%). Respondents licensed in different states recommended different sanctions (see Table 5).

Table 5.
Recommended sanctions frequency.^a

Revocation Suspension Probation Limited Scope of Practice Reprimand Fines Recovery of Costs Exams CEU Assessment Supervised Practice Public Record Reflection or Apology

State n % n % n % n % n % n % n % n % n % n % n % n % n %

Survey 1: Kathleen

Florida 59 24.1 122 49.8 86 35.1 38 15.5 82 33.5 89 36.3 64 26.1 17 6.9 94 38.4 29 11.8 97 39.6 55 22.4 71 29.0

Minnesota 160 28.5 275 49.0 180 32.1 77 13.7 179 31.9 176 31.4 131 23.4 52 9.3 209 37.3 78 13.9 234 41.7 143 25.5 152 27.1

Ohio 237 32.7 372 51.4 176 24.3 91 12.6 197 27.2 197 27.2 169 23.3 79 10.9 270 37.3 75 10.4 238 32.9 195 26.9 170 23.5

Oklahoma 26 27.7 50 53.2 28 29.8 11 11.7 26 27.7 32 34.0 30 31.9 7 7.4 31 33.0 7 7.4 37 39.4 17 18.1 27 28.7

Oregon 23 26.7 46 53.5 31 36.0 11 12.8 30 34.9 24 27.9 19 22.1 11 12.8 38 44.2 11 12.8 47 54.7 25 29.1 35 40.7

Rhode Island 6 18.8 19 59.4 7 21.9 2 6.3 14 43.8 5 15.6 1 3.1 1 3.1 14 43.8 4 12.5 9 28.1 5 15.6 6 18.8

Survey 2: Jennifer/John

Florida 61 29.0 111 52.9 53 25.2 39 18.6 66 31.4 43 20.5 52 24.8 14 6.7 65 31.0 14 6.7 71 33.8 40 19.0 49 23.3

Minnesota 126 30.7 211 51.3 153 37.2 76 18.5 136 33.1 87 21.2 74 18.0 50 12.2 152 37.0 59 14.4 197 47.9 91 22.1 136 33.1

Ohio 248 39.9 312 50.2 138 22.2 84 13.5 145 23.3 101 16.2 93 15.0 56 9.0 179 28.8 42 6.8 225 36.2 142 22.8 152 24.4

Oklahoma 20 41.7 25 52.1 13 27.1 8 16.7 18 37.5 10 20.8 14 29.2 7 14.6 16 33.3 4 8.3 23 47.9 9 18.8 14 29.2

Oregon 17 27.9 36 59.0 15 24.6 9 14.8 19 31.1 7 11.5 13 21.3 6 9.8 17 27.9 9 14.8 28 45.9 15 24.6 16 26.2

Rhode Island 10 32.3 17 54.8 7 22.6 3 9.7 10 32.3 8 25.8 6 19.4 4 12.9 18 58.1 5 16.1 16 51.6 6 19.4 13 41.9

^a
Respondents could select more than one.

Discussion and Applications to Practice

The present analysis sheds light on social workers’ views of wrongdoing through the lens of board membership and state of licensure. These variables impact at least some social workers’ perceptions of certain types of misconduct. That influence, while having just a negligible or weak effect across variables, may serve as a helpful window into understanding the differences in settling complaints brought before state licensing boards. Vignettes included one changed detail (e.g., perceived gender) to study nuances in perception, revealing that some factors involved in wrongdoing are more salient than others.

The original version of each survey vignette was based on previously decided cases brought before different state licensing boards. As the licensing board members did in those cases, respondents in this study considered each to be serious enough to warrant at least minimal disciplinary action. Respondents across states and board member status tended to agree about which cases required higher levels of seriousness and importance to enact discipline. For instance, Kathleen's vignette centered on her accepting a substantial loan from a client. Respondents tended to agree that this action was serious and in need of discipline, regardless of location or board status.

The previously published results of this study suggested that social workers’ assessments of their peers’ misconduct related more to the details of the vignette and less about the characteristics of the social worker or clients involved (Gricus & Wysiekierski, 2022). The analysis of results as presented in this article leads to reflections about the influence that respondents’ characteristics, namely status as a board member and their licensure state, may have had, suggesting that examining the characteristics of respondents may improve our understanding of important decision-making factors.

The significant differences among the results reveal important contextual factors. The gender of the clients involved in Trevor's case, the perceived race of the social worker in Lindsey/La-Teesha's case, and the status of Michael's fraud investigation were key factors in viewing the situation. These differences suggest the possibility of bias not previously seen in other analyses of this dataset (Gricus & Wysiekierski, 2022). Erick's practicing without a license contained the most variability, which may be explained by the variety of regulations defining who and when a person must be licensed in any given state or territory.

Recommended sanctions for the most troubling vignettes followed similar patterns for board status; however, there was wide variability in responses when the state of licensure was isolated, reflecting the kinds of inconsistencies found in Boland-Prom's dataset (2009a) and reported by Davis (2020). These discrepancies may be explained by unpublished factors in the cases brought before licensing boards or state-specific statutes and may be an area of further study. The lack of a national database for disciplinary action for all licensure levels or a consistent record of case details complicates a true analysis of national trends.

The findings in this study suggest a relationship between state and ratings, not causality. Several factors may be at play when considering decision-making across disciplines. Dietrich (2010) suggests that individual differences such as age, socioeconomic status, and intellectual capacity may impact the decisions people make. Social workers’ beliefs about what they consider ethical can also vary by the size of the community where they practice (Croxton et al., 2002) and the strength of their religious beliefs (Landau & Osmo, 2003), however, the effects of licensure state on decision-making require further examination.

The differences found among social workers licensed in different states are significant for some types of misconduct, supporting a cautious recommendation for national licensing standards and processes. The recent increases in the use of telehealth for service delivery further prioritize the need for consistent standards across states, as a social worker practicing in one state is responsible for understanding the laws in the states where their clients are at any given moment during service delivery (Barsky, 2017). The differences found between the board and nonboard members suggest that these groups do not apply seriousness and importance to discipline similarly to all types of professional conduct.

One to ten percent of licensed professionals are involved in claims of misconduct, though, as may be expected, there are differences among states (Magiste, 2020). For example, Ohio, a state included in this study, has been the subject of two recent analyses related to misconduct. Davis (2020) identified Ohio as sanctioning clinical social workers at a rate of 7.67%. More than 25% of the cases reported to the National Practitioner Data Bank from Ohio were for continuing education compliance or competency issues. In his study of 592 files of misconduct covering nearly 30 years and all license types in Ohio, Magiste (2020) found a 0.05% prevalence of misconduct across licensees, 37.3% of which were for licensing issues. The most frequent sanctions issued by the Ohio licensing board across violation categories were revocation of license, suspension of licensure, and reprimand (Davis, 2020). Similar analyses in other states may help to further understanding of patterns and lead to more consistent processes and practices.

Pope and Keith-Spiegel (2008) suggest that it is “easier to question the ethics of others … while putting our own beliefs, assumptions, and actions off-limits. Questioning someone's ethical decisions and behavior must be a two-way street” (p. 641). Pomerantz et al.'s (1998) seminal study asked respondents to label professional practice actions on an ethical scale but did not elicit a ranking of actions deemed unethical. For example, social workers rated “sex with a clinical supervisee” as “unquestionably not ethical,” (Pomerantz et al., 1998) a situation included in the present study in Roger's vignette. While 39.4% of nonboard members (n = 963) and 43.1% of board members (n = 174) in the present study indicated that this type of violation was the most troubling of the four they assessed, more considered Jennifer's/John's engaging in lies and bribery to be worse.

Adding a priority ranking hierarchy to each vignette like the Ethical Principles Screen (Dolgoff et al., 2012) or the NASW's Code of Ethics six ethical principles (NASW, 2021) could help shed light on social workers’ reasoning. Meggison’s (2020) piloted instrument—the Perceptions of Ethical Misconduct Scale (PEMS) may also provide a key to further understanding. The NASW Code of Ethics is identified by the profession as the reference point for resolving dilemmas or ranking priorities; however, practicing social workers consider their own experiences over the Code (DiFranks, 2008). The social work profession does not issue formal opinions about complicated cases, leaving considerable room for interpretation (Mattison, 2000). Some of these interpretations can be seen in the present quantitative study. A qualitative analysis of vignettes examined through a model like Strom-Gottfried’s (2015) Six Question Model would also provide valuable information about interpretation and reasoning.

Other segments of the results reveal perception subtleties. Trevor and Lindsey/La-Teesha's vignettes shared one commonality—the social worker's admission of wrongdoing, the only vignettes in the two survey versions to do so. This finding may suggest that social workers could face fewer consequences if admitting to a mistake is correlated with a decrease in the importance of initiating disciplinary action. In the last 25 years, studies have examined the effects of physicians admitting errors (Hawkes, 2015), supplying evidence of a reduction in lawsuits for doctors who admit mistakes; however, there is no published evidence that such admissions reduce penalties by licensing boards.

The variables examined in the present study appear to be unique to the current literature available on social work regulation. The study had good generalizability for the six states included in the study; demographics collected from respondents mirror the U.S. social work workforce for gender, race, and age (Salsberg et al., 2017), and include different practice settings and regions of the country. The large sample available for this study is uncommon in social work literature. While the response rate is low, the sample included the total population of licensed social workers in six U.S. states, increasing the generalizability more than a random sample.

As with any study, there were limitations. The sample may not reflect the outcomes found across the United States. Respondents selected a narrow spectrum of responses, resulting in a collapsing of the Likert scales for analysis. It is possible that respondents perceived the vignettes, though commonly seen by licensing boards, as too extreme for the survey, leaving little room for variation in ratings. Since all vignettes involved some form of unprofessional behavior and the survey did not include a neutral vignette as a control, respondents may have tended toward higher ratings of seriousness and importance to discipline. The default effect may also be a factor, as respondents may have favored their earlier selection or the location of the default answer (set at 3.5 across dependent variables) instead of deciding the next vignette on its unique details (Jachimowicz et al., 2019). The present study did not account for this effect, aside from including randomization whenever possible, and may have been mitigated by restricting respondents’ choices after selecting a score. Restricting answer choices would have also served as a method for ranking the vignettes more objectively.

The survey did not include questions about whether the participants had engaged in the behavior outlined in the vignette themselves. Jayaratne et al. (1997) elicited this information about social workers’ engagement in various boundary issues and found, for example, that 6.7% of their sample had borrowed or lent money to a client. Having this information in the present study would have aided in understanding responses to Kathleen's vignette, for example.

The dataset for this study is large, with many avenues for continued analysis. A forthcoming manuscript will focus on the personal and professional characteristics of survey respondents, including the effects of variables such as age, political viewpoint, state, and license type on the vignettes. In addition, the author has contact information for a subset of respondents who expressed interest in a follow-up qualitative study to explore decision-making processes that led to respondents’ conclusions. The author welcomes collaboration on further analysis and interpretation of the data. This study is not a comparative analysis of the legislative or regulatory policies and administrative characteristics of any one state or territory, though such a comparison may be useful for furthering understanding in this area.

When state social work licensing boards review allegations of misconduct, they assess the social worker's actions and assign sanctions, if warranted. The results in the present analysis suggest that two factors—namely, the licensure state and board membership—are important in shaping the perceptions of the seriousness and importance to enact discipline for others’ misconduct. Why one state's evaluation of a similar infraction would be decided differently in another state can be difficult for social workers to understand. As addressed in the review of the literature, Boland-Prom’s (2009a) dataset of disciplinary action taken by state licensing boards offers a glimpse of the challenges inherent in the current structure. This analysis puts forth an argument for more consistent standards and processes for regulation.

Category of Violation^a	Survey 1 (Version 1)^b	Survey 1 (Version 2)^b	Changed Variable
Dual relationships	Kathleen has been a licensed social worker at the bachelor's level for nine years. Kathleen claims that she and Anne, an elderly client, were friends that Anne offered to loan her over $2400. Kathleen has indicated that she plans on repaying Anne the money she borrowed per a contracted agreement. However, Kathleen has not yet begun making the payments.	Kathleen has been a licensed social worker at the bachelor's level for nine years. Anne, an elderly client, reports that she agreed to lend Kathleen over $2400. Kathleen has indicated that she plans on repaying Anne the money she borrowed per a contracted agreement. However, Kathleen has not yet begun making the payments.	Viewpoint of the relationship
Crimes	Michael has been a licensed clinical social worker for over 25 years. He was convicted of 10 counts of Medicaid fraud and served time in jail. Michael reports he was innocent and that he was taken advantage of, claiming that he is “computer illiterate” and relied on someone else to type his notes and file the claims.	Michael has been a licensed clinical social worker for over 25 years. He was accused of 10 counts of Medicaid fraud and served time in jail. Michael reports he was innocent and that he was taken advantage of, claiming that he is “computer illiterate” and relied on someone else to type his notes and file the claims.	Conviction versus accusation
Below standards of care	Trevor received his MSW 4 years ago and his clinical license 2 years ago. He works at a therapeutic day school for kids with emotional and behavioral challenges. A colleague filed a complaint with the licensing board that Trevor did not notify his supervisors of a reportable incident: A minor female client said she had been physically threatened by a minor male client and was fearful for her safety. Trevor admitted he failed to report and document the incident.	Trevor received his MSW 4 years ago and his clinical license 2 years ago. He works at a therapeutic day school for kids with emotional and behavioral challenges. A colleague filed a complaint with the licensing board that Trevor did not notify his supervisors of a reportable incident: A minor male client said he had been physically threatened by a minor female client and was fearful for his safety. Trevor admitted he failed to report and document the incident.	Gender of clients involved
License-related	Erick received his MSW degree five years ago and has been employed in a social work role. He has not taken steps to become licensed. The state law where Erick lives requires MSW graduates to obtain a license within 6 months of practicing.	Erick received his MSW degree seven months ago and has been employed in a social work role. He has not taken steps to become licensed. The state law where Erick lives requires MSW graduates to obtain a license within 6 months of practicing.	Length of time involved

Category of Violation^a	Survey 2 (Version 1)^b	Survey 2 (Version 2)^b	Changed Variable
Poor basic practice	Jennifer has been a licensed social worker at the bachelor's level for less than 2 years. The [licensing] board received a complaint from Jennifer's employer that Jennifer has not conducted home visits or services she claimed to have provided to at least one client. The client, Crystal, said she had seen not Jennifer for these visits and did not recognize the signature as her own on signed documents. Jennifer allegedly asked Crystal to lie saying that they saw one another. She promised Crystal that her child protection case could be closed sooner if she went along with it.	John has been a licensed social worker at the bachelor's level for less than 2 years. The [licensing] board received a complaint from John's employer that John has not conducted home visits or services he claimed to have provided to at least one client. The client, Crystal, said she had not seen John for these visits and did not recognize the signature as her own on signed documents. John allegedly asked Crystal to lie saying that they saw one another. He promised Crystal that her child protection case could be closed sooner if she went along with it.	Gender of social worker
Supervision below the standards of care	Roger has been a clinical social worker for 10 years and is a field instructor for students in their internships. He allegedly engaged in sexual activity with one of his current female students.	Roger has been a clinical social worker for 10 years and is a field instructor for students in their internships. He allegedly engaged in sexual activity with one of his current male students.	Perceived sexual orientation of social worker
Billing	Lindsey has had her LMSW (nonclinical, master's level) license for 10 years. She was accused of submitting incomplete and late assessments and progress notes. While investigating these accusations, Lindsey's employer located billed services that did not occur. Lindsey resigned from her position and decided to not continue as a practicing social worker.	La-Teesha has had her LMSW (nonclinical, master's level) license for 10 years. She was accused of submitting incomplete and late assessments and progress notes. While investigating these accusations, La-Teesha's employer located billed services that did not occur. La-Teesha resigned from her position and decided to not continue as a practicing social worker.	Perceived race of social worker
Impaired social worker	Sam has her clinical license and works as an alcohol and drug abuse counselor. Sam has an active addiction to methamphetamine. This has resulted in her being out of work sick often and affecting her while she is at work.	Sam has her clinical license and works as an alcohol and drug abuse counselor. Sam has an active addiction to alcohol. This has resulted in her being out of work sick often and affecting her while she is at work.	Type of substance

Characteristic (n = 5,388)	Nonboard Member(n = 4,930)	Board Member(n = 458)
Age
21–32	774	15.7	69	15.1
33–39	733	14.9	80	17.5
40–49	896	18.2	93	20.3
50–59	892	18.1	85	18.6
60 +	947	19.2	66	14.4
Did not provide	688	14.0	65	14.2
Length of practice
< 15 years	2,470	50.1	247	53.9
15 + years	2,451	49.7	211	46.1
Did not provide	10	0.3	0	0.0
State
Florida	818	16.6	42	9.2
Minnesota	1,458	29.6	153	33.4
Ohio	2,110	42.8	213	46.5
Oklahoma	227	4.6	34	7.4
Oregon	214	4.3	14	3.1
Rhode Island	103	2.1	2	0.4
Practice setting
Private organization/nonprofit social services	877	17.8	73	15.9
Community mental health/substance use agency	557	11.3	63	13.8
Hospital/medical clinic	781	15.8	63	13.8
School/other youth-serving organization	331	6.7	35	7.6
Federal/state/local government (including child welfare, DHS, VA)	671	13.6	71	15.5
Private practice/self-employed	533	10.8	42	9.2
Other (corrections, higher ed., for-profit	896	18.2	92	20.1
Did not provide	285	5.8	18	4.1
License level
Bachelor's level (e.g., BSW, LSW, LBSW)	1,123	22.8	137	29.9
Master's level, not independent (e.g., CSW, LMSW, LGSW)	801	16.2	86	18.8
Master's level, independent, nonclinical (e.g., CSW, LISW)	420	8.5	36	7.9
Master's level, independent, clinical (e.g., LCSW, LCSW-C, LICSW)	2,556	51.9	195	42.6
Other	21	0.4	4	0.9
Did not provide	9	0.01	0	0.0

		Not Serious	Serious	Very Serious
Unchanged factor	Nonboard	109	90.1	260	92.2	855	91.2
Board	12	9.9	22	7.8	82	8.8
Changed factor	Nonboard	147	88.0	327	92.6	692	89.4
Board	20	12.0	26	7.4	82	10.6
	State
Unchanged factor	Florida	27	22.3	60	21.3	129	13.8
Minnesota	45	37.2	89	31.6	254	27.1
Ohio	36	29.8	102	36.2	446	47.6
Oklahoma	2	1.7	15	5.3	53	5.7
Oregon	7	5.8	9	3.2	41	4.4
Rhode Island	4	3.3	7	2.5	14	1.5
Changed factor	Florida	35	21.0	56	15.9	111	14.3
Minnesota	62	37.1	122	34.6	200	25.8
Ohio	53	31.7	130	36.8	379	49.0
Oklahoma	2	1.2	21	5.9	47	6.1
Oregon	12	7.2	16	4.5	25	3.2
Rhode Island	3	1.8	8	2.3	12	1.6

		Not Important	Important	Very Important
Variable	Board status
Unchanged factor	Nonboard	129	91.5	315	91.8	769	91.4
Board	12	8.5	28	8.2	72	8.6
Changed factor	Nonboard	176	89.3	382	90.3	582	89.8
Board	21	10.7	41	9.7	66	10.2
	State
Unchanged factor	Florida	26	18.4	66	19.2	122	14.5
Minnesota	60	42.6	107	31.2	218	25.9
Ohio	34	24.1	133	38.8	409	48.6
Oklahoma	4	2.8	14	4.1	51	6.1
Oregon	11	7.8	14	4.1	30	3.6
Rhode Island	6	4.3	9	2.6	11	1.3
Changed factor	Florida	37	18.8	59	13.9	97	15.0
Minnesota	81	41.1	140	33.1	156	24.1
Ohio	60	30.5	170	40.2	320	49.4
Oklahoma	4	2.0	24	5.7	43	6.6
Oregon	13	6.6	16	3.8	24	3.7
Rhode Island	2	1.0	14	3.3	8	1.2

	Revocation	Suspension	Probation	Limited Scope of Practice	Reprimand	Fines	Recovery of Costs	Exams	CEU	Assessment	Supervised Practice	Public Record	Reflection or Apology
Survey 1: Kathleen
Florida	59	24.1	122	49.8	86	35.1	38	15.5	82	33.5	89	36.3	64	26.1	17	6.9	94	38.4	29	11.8	97	39.6	55	22.4	71	29.0
Minnesota	160	28.5	275	49.0	180	32.1	77	13.7	179	31.9	176	31.4	131	23.4	52	9.3	209	37.3	78	13.9	234	41.7	143	25.5	152	27.1
Ohio	237	32.7	372	51.4	176	24.3	91	12.6	197	27.2	197	27.2	169	23.3	79	10.9	270	37.3	75	10.4	238	32.9	195	26.9	170	23.5
Oklahoma	26	27.7	50	53.2	28	29.8	11	11.7	26	27.7	32	34.0	30	31.9	7	7.4	31	33.0	7	7.4	37	39.4	17	18.1	27	28.7
Oregon	23	26.7	46	53.5	31	36.0	11	12.8	30	34.9	24	27.9	19	22.1	11	12.8	38	44.2	11	12.8	47	54.7	25	29.1	35	40.7
Rhode Island	6	18.8	19	59.4	7	21.9	2	6.3	14	43.8	5	15.6	1	3.1	1	3.1	14	43.8	4	12.5	9	28.1	5	15.6	6	18.8
Survey 2: Jennifer/John
Florida	61	29.0	111	52.9	53	25.2	39	18.6	66	31.4	43	20.5	52	24.8	14	6.7	65	31.0	14	6.7	71	33.8	40	19.0	49	23.3
Minnesota	126	30.7	211	51.3	153	37.2	76	18.5	136	33.1	87	21.2	74	18.0	50	12.2	152	37.0	59	14.4	197	47.9	91	22.1	136	33.1
Ohio	248	39.9	312	50.2	138	22.2	84	13.5	145	23.3	101	16.2	93	15.0	56	9.0	179	28.8	42	6.8	225	36.2	142	22.8	152	24.4
Oklahoma	20	41.7	25	52.1	13	27.1	8	16.7	18	37.5	10	20.8	14	29.2	7	14.6	16	33.3	4	8.3	23	47.9	9	18.8	14	29.2
Oregon	17	27.9	36	59.0	15	24.6	9	14.8	19	31.1	7	11.5	13	21.3	6	9.8	17	27.9	9	14.8	28	45.9	15	24.6	16	26.2
Rhode Island	10	32.3	17	54.8	7	22.6	3	9.7	10	32.3	8	25.8	6	19.4	4	12.9	18	58.1	5	16.1	16	51.6	6	19.4	13	41.9

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Michelle Gricus

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