The Role of Voice Suppression in Case Managers’ Job Satisfaction and Retention: A Focus Group Inquiry

With the goal of improving child well-being, child welfare agencies have begun to focus on the child welfare workforce and to advance strategies that address job satisfaction and retention. A qualitative approach was employed to gather the perspectives of case managers regarding these important issues. Ten foster care case managers participated through three focus groups. Responses were solicited using a semi-structured set of questions primarily focused on critical factors that affect job satisfaction and turnover. Through inductive coding, a prominent theme emerged regarding the suppression of case managers’ voices. Case managers described the suppression of their voices during decision-making in foster care cases by five types of actors, i.e., supervisors, judges, guardians ad litem, attorneys, and funding agency representatives. Further, they described the negative effects this experience had on both themselves and the children and families they serve. These results demonstrate the importance of inter-professional interactions in the foster care field. Further research is needed to identify the extent of this problem and the ways in which interactions can be improved and all voices can be considered.

The field of child welfare is marked by longstanding workforce issues, including low case manager morale and high case manager turnover (Edwards & Wildeman, 2018;Strolin et al., 2006). In response to these challenges, researchers and policymakers have issued recommendations for reform (Briar-Lawson, 2014;Briar-Lawson & Zlotnick, 2003;Casey Family Programs, 2017;Pecora et al., 2018;Willis et al., 2016). Frequently absent from the process used to develop these recommendations is the perspective of case managers on what they need to effectively carry out their work tasks, what they need to be satisfied with their work, and what they need to remain on the job. Though this study began with an evaluation of a child welfare workforce initiative aimed at case manager morale and retention, the qualitative portion of the evaluation allowed for the inclusion of the case managers' perspective. This article reports on one of the threats to morale and retention that emerged from the qualitative portion, namely voice suppression, and provides a description of the suppression, its sources, and its effects from the perspective of case managers.

Literature Review
Recent qualitative research points to the importance of respecting the perspective of case managers and the consequences of not doing so.  use the phrase "wanting a voice" when describing one of the themes that arose when they asked former child welfare workers "what would have helped [them] remain at the job?" (p. 82). They found that former workers wanted to play a role in the agency's improvement and felt punished for trying to participate in problem-solving. Their study is the primary source of information on voice suppression in the child welfare field. Outside of this study, the concept of voice suppression has not been directly examined. While the suppression of the case manager's voice in child welfare settings is seldom studied, the literature does include a focus on related concepts and their effects on case managers and case outcomes.
Organizational culture and climate are two concepts that are intertwined with voice suppression. The norms and mechanisms that guide case managers' expression are part of organizational culture, and the tone and spirit of the response that meets case managers' expression is part of climate. The organizational culture and climate of child welfare agencies are important variables that have been found to affect both case managers and clients. Glisson et al. (2012) found that case managers had significantly higher job satisfaction when working for child welfare agencies with organizational cultures characterized by flexibility as opposed to rigidity. Job satisfaction is also higher when organizational climates are characterized by case managers' sense of positive engagement with their work and positive interactions with others in the work environment (Glisson et al., 2012). Organizations with these types of climates appear to produce better outcomes. Specifically, children show greater improvement in well-being measures when served by child welfare agencies where case managers report positive engagement and positive interactions (Glisson & Green, 2011;Glisson & Hemmelgarn, 1998). Likewise, organizational culture has a significant relationship with case managers' intention to remain employed with the agency (Ellett, 2009;Kim & Kao, 2014;. Further, this research has been translated into an organizational culture and climate intervention that was successful in reducing case manager turnover (Glisson et al., 2006).
Since the relationship between case managers and supervisors involves frequent communication regarding cases, supervision may serve as a venue in which case managers' perspectives may be elicited or suppressed. Qualitative research with case managers points to the importance of supervision (Ellett et al., 2007;Jacquet et al., 2007;Morazes et al., 2010). In a study of 369 case managers, Ellett et al. (2007) found that many believed supportive supervision was connected to retention. Likewise, Jacquet et al. (2007) and Morazes et al. (2010) conducted interviews with 387 case managers, many of whom stated that the quality of the relationship with their supervisor was a major factor in their decision to stay or leave. Quantitative research has repeatedly identified a relationship between supportive supervision and case manager retention (Chen & Scannapieco, 2010;Chenot et al., 2009;Dickinson & Perry, 2002;Jacquet et al., 2007;Kim & Kao, 2014;Lee et al., 2011;Smith, 2005;Yankeelov et al., 2009). In addition, supportive supervision has been found to be a significant predictor of the case manager's sense of empowerment and job satisfaction (Barth et al., 2008;Cearley, 2004;Lee et al., 2011;Strand & Dore, 2009). In response to these findings, the field has invested in various types of interventions to improve supervision and thus stabilize the workforce (Collins-Camargo & Millar, 2010;Landsman, 2007;Lietz & Rounds, 2009). In previous studies, child welfare researchers examined the concepts of autonomy and participation in decision-making. These two concepts may be thought of as separate ends of a spectrum, with one representing independence and another representing collaboration. However, both involve inclusion of the case managers' perspectives. Early research identified lack of autonomy as having a significant effect on case managers' intention to quit (Mor Barak et al., 2001). However, more recent studies have produced mixed results. Kim and Kao (2014) found autonomy to have a moderate effect on turnover intention, while  found no significant relationship between these two variables. The lack of a significant finding in the latter study may have been due to measurement error, since the autonomy subscale did not meet minimum requirements for reliability . Participation is another variable that has been described in the literature as an important factor in retention. As described earlier,  qualitative study found that case managers who left their positions believed they would have stayed if they had been given a voice in agency discussions. Quantitative research further supports the idea that participation in decision-making is related to retention (Hopkins et al., 2010;Mor Barak et al., 2006).

Contribution of Present Study
Much of the existing research regarding the case manager's experience has been conducted based on presumptions regarding these experiences, and thus, entailed methods that limited the emergence of new themes. In fact, most of the data for the present study were collected during the course of an evaluation that used a deductive method. However, the evaluation also included an inductive approach through the use of focus group discussions where case managers expressed their beliefs regarding morale and retention. The research question for this portion of the study was as follows: What factors do case managers identify as influential in shaping job satisfaction and retention?

Method Design
This research was conducted during the course of a mixed-methods evaluation of a workforce initiative. The administrators of the agency were seeking to boost job satisfaction, decrease turnover, and improve case outcomes through the following three strategies: reducing caseload sizes, adding a career advancement ladder, and supplementing the existing training curriculum. The evaluation assessed the effects of these strategies through several data sources: survey and focus group data from case managers and secondary data regarding case outcomes and turnover rates. While the evaluation focused primarily on the effects of the three workforce strategies, the focus groups allowed case managers to offer their perspectives on additional factors that they believed were influential in the morale and retention of case managers. Three focus groups were held during standard office hours in the agency's private conference rooms. Before discussions began, participants were informed of their rights and given a paper copy of the summary explanation of research. This consent process, which is typically used in studies classified as exempt, was approved by the university IRB before the focus groups were held.

Sample
The participants were recruited using two methods: announcements within the agency and emails sent directly to the case managers by the principal investigator. This diversity of recruitment methods allowed participants to sign up privately through the researcher located outside of the agency or publicly through the agency's staff. The final sample consisted of ten case managers who handled cases involving in-home supervision and outof-home placement. The ten participants represented 29% of the case managers employed by the agency. To protect the case managers' identities, demographic information was not requested. However, the principal investigator noted that the sample included participants of diverse ethnicities. Further, they had diverse levels of work experience, with some being in their first year of employment at the agency and others having had multiple years of experience.

Data Collection
Case manager perceptions were elicited through the focus groups using a semistructured set of questions. The set of questions was primarily derived from the goals of the evaluation. As such, the majority of the questions addressed the effects of training, reduced caseload levels, and an enhanced career ladder on job satisfaction, turnover, and case outcomes. The portion of the study featured in this article includes some data from responses to these questions but is largely based on responses to the remaining questions that sought to identify any important issues that were not addressed in the more structured questions. Examples include the following: "Do you want to say anything else about morale?" "What do you believe is the leading factor in caseworker turnover?" "Anything else to add?" Two researchers attended each focus group and asked these questions as well as follow-up questions.

Analysis
The analytic strategy adapted over time, shifting from the original goal of evaluation to the goal of describing the experiences of the case managers. For the purposes of evaluation, the transcripts were initially analyzed by the principal investigator using a deductive coding strategy that facilitated the collection of information regarding the effects of the workforce initiative strategies. In line with the goals of the evaluation, codes that represented positive, negative, and neutral effects of the initiative's strategies were created before coding. During this initial phase of coding, the pre-existing codes failed to capture some of the experiences that case managers reported, in particular the experience of voice suppression and the profound effects this suppression had on themselves and their clients. Therefore, a second round of coding was conducted using an inductive approach with a focus on voice suppression. The transcripts were reviewed, and all passages representing voice suppression were identified. Using axial coding, these passages were classified into the following three categories: voice suppression; sources of suppression; and effects of suppression. Coding then commenced within each category. Coding in the first category (voice suppression) was descriptive in nature. Coding in the second category (sources of suppression) was also descriptive. Passages in the third category (effects of suppression) were analyzed through causation coding (Miles et al., 2020).

Suppression of Case Managers' Voices
One of the primary concerns that case managers expressed during the focus groups was suppression of their voices. The case managers in the sample repeatedly described situations in which they voiced or attempted to voice their perspectives, but were overridden by other actors in the child welfare system. The examples they provided were all focused on the management of cases. As one participant stated: We're not looked at as the expert on our case.
The data reveal a frustration with this experience of having their voices suppressed, since they believed that they had valid perspectives that should be considered during decisionmaking.
They have to take more into consideration of what the case manager sees on a daily basis. They're the ones going into the home. They're the ones coming back with tears in their eyes.
As demonstrated by the above passage, the case managers described having a unique foundation of knowledge on their cases based on their direct experience with the families. When they presented these perspectives, they were met with direct and indirect forms of voice suppression (e.g., ignored, discounted, and silenced).

Sources of Suppression
The case managers described multiple actors who suppressed their voices. One participant characterized this situation as follows: There are so many people that play a part that override everything or can override everything you say or do.
Analysis revealed that these groups of people could be categorized into five sources of suppression. One of the sources was internal to the foster care agency, while the others were external. Supervisors were described as an internal source of suppression. External sources of suppression included professionals within the funding agency and the legal system (e.g., judges, attorneys, and guardians ad litem).
Supervisors. Supervisors were said to suppress case managers' voices in case decision-making and in the assignment of risky tasks. In regards to case decision-making, one participant described this suppression in the following manner: If a supervisor does not allow the case manager to explain what they want or how they feel, or just says "No, it's gonna be this way," you've lost that case manager…You're not even giving them a chance to explain. And they're the ones in the field doing it.
Supervisors were also said to suppress case managers' concerns regarding safety. Participants described the safety risks they took when interacting with clients who had histories of extreme violence. This interaction was considered particularly risky when they were alone with parents during home visits or alone with foster youths while transporting them for care. Their supervisors were described as not being open to their concerns.

[Supervisors] don't look at it as you don't feel comfortable doing it. [They look at it] as you're trying to get out of work…And that's not really the case.
They tell you, "well, you have to do it."

We don't have a choice. You have to do it and you get no say in that.
In these ways, case managers felt their voices were suppressed by supervisors.
Funding Agency Representative. Since this was a private agency, the case managers' choices were partially controlled by the agency that funded the foster care contract. The interactions with this funder were marked by voice suppression.

Sometimes, we see a problem with a family that we're trying to remediate, so we can build this family back up. But then, we're having our funding agency say "well, we're not going to fund that because it wasn't in the case plan or the judge didn't order that."
In this context, the representative of the funding agency had the power to override the case manager's recommendations.
Legal Professionals. The legal system was a venue in which multiple actors, specifically judges, lawyers, and guardians ad litem, encroached upon case managers' voices. These actors were described in different ways, with judges being the most respected of the three. They expressed a desire for judges to give their opinions greater consideration, particularly since they found the judges to be out of date on child protection issues.
When the judge says they're going home, sometimes we want to jump up and down and say no. But we don't have a choice. The judge makes the final decision. We get that, but it's just so sad. Sometimes things are not really discussed. This is the way it's going to be. And you just can't go any further. That's very frustrating.
The relationship with the lawyers who represented the state took on a more hostile tone, with the suppression of case managers' voice being overt and intentional.

It's very frustrating when you're sitting there and you're trying to say something and [the lawyers] don't want to hear you or they don't want you to tell the judge or they're not backing us up.
[The lawyers] yell at you sometimes when you try to speak up to defend yourself in court. They'll tell you to hush up.
The guardians ad litem also functioned in a way that resulted in the suppression of case managers' voices.
I would never try to send a kid home if I don't think it's a safe environment. When you think that's ready, you have to convince 50 other people to jump on board with you…The [guardian ad litem] can object.
The participants believed that the court system elevated the voices of guardians over that of case managers.

It's like what [the guardians] say in court is the gospel…A lot of times the judge sides with the guardians.
The participants expressed great concern with this, since they believed that guardians did not have as much contact with the family and did not have the training necessary for this type of work.

Perceptions of the Effects of Voice Suppression
These forms of suppression were described as affecting both the case manager and the case outcomes. Study participants believed that positive outcomes for the child were more difficult to attain when court decisions were based on uninformed opinions that overruled their own recommendations. In addition, tasks such as home visits had to be postponed in order to respond to perspectives, specifically supervisors' voices, that were more valued by the system than their own. One case manager presented the following case as an example of these effects on case outcomes and how this then circles back to affect the case manager.
[The voice suppression] stalls reunification. Mom has been doing everything underneath the moon and stars. We see a behavioral change. We see a parent from the very beginning who has been aggressive and tenacious as far as going out and doing their case plans and changing for their kids. And then we're halted by the [guardian ad litem] who says, "Well, I think that, you know, there's some kind of threat. I can't put my finger on it, but there's some type of threat in there." Our opinions, our education, our knowledge means nothing at times. So that goes back to morale and that goes back to retention.
In this way, participants' descriptions of voice suppression reflected a complex interaction of negative effects on both the case manager and the family.

Discussion
One of the key findings of this study is that case managers described their work experience as being marked by voice suppression. This finding aligns with the results of Griffiths and Royse (2017) who interviewed case managers and found that voice suppression was a key issue for the participants in their sample. However, much of the data from their study reflected voice suppression during efforts to improve the agency as a whole, as opposed to voice suppression during case-level decision-making. It should be noted that Ellett et al. (2007) and Morazes et al. (2010) conducted similar qualitative studies on turnover and did not report voice suppression as a major issue of concern. Therefore, the possibility remains that this finding is sample-specific. On the other hand, the theme of voice suppression might be present in these studies but entangled with other themes related to organizational culture or to the source of suppression, such as supervisory relationships. Similarly, voice suppression might be an inherent part of organizational rigidity, lack of autonomy, and lack of participation in decision-making, which have all been studied using quantitative methods (Glisson et al., 2012;Hopkins et al., 2010;Kim & Kao, 2014;Mor Barak et al., 2001, 2006. The second key finding is that case managers experienced voice suppression from multiple sources, including supervisors and legal professionals. Past research, both quantitative and qualitative, provides a wealth of evidence that supervision is a critical factor in the child welfare workplace (Barth et al., 2008;Cearley, 2004;Chen & Scannapieco, 2010;Chenot et al., 2009;Dickinson & Perry, 2002;Ellett et al., 2007;Jacquet et al., 2007;Kim & Kao, 2014;Lee et al., 2011;Morazes et al., 2010;Smith, 2005;Strand & Dore, 2009;Westbrook & Crolley-Simic, 2012;Yankeelov et al., 2009). This study adds to this body of literature through additional detail on the ways in which supervisors suppress the case managers' voice, specifically their concerns regarding their own safety and the well-being of the children on their caseload. Likewise, this finding adds detail to the literature regarding the relationship between case managers and legal professionals. While Ellett et al. (2007) and Morazes et al. (2010) both describe case managers' frustration with the courts, the nature of the relationships with legal professionals and the ways that these professionals suppress the case manager's voice are seldom examined.
The third key finding is that the case managers in the sample believed that voice suppression had negative effects on case managers and clients. The literature provides some support for a negative effect on case managers. Though only one study directly suggests a relationship between voice suppression and turnover , many others focus on related concepts that affect job satisfaction and turnover. This finding regarding voice suppression reflects a desire for both autonomy and participation in decision-making, which have been found to have significant effects on case managers (Hopkins et al., 2010;Kim & Kao, 2014;Mor Barak et al., 2001;2006). The findings also reflect a frustration with rigidity in culture, i.e., "no flexibility in carrying out their jobs" which Glisson and colleagues (2012) found to be significantly related to case manager outcomes (p. 625). Little research has focused on the relationship between these concepts and client outcomes, but what is available suggests that the way child welfare professionals interact with one another affects child well-being (Glisson & Hemmelgarn, 1998).

Implications for Practice
These results highlight the importance of addressing the relationship between case managers and their professional partners (e.g., judges, attorneys, and guardians ad litem), which might be improved through inter-professional education. Evaluations of interprofessional education in the field of healthcare have yielded evidence of positive impact for not only organizational culture and collaborative team behavior, but also service quality and patient outcomes (Reeves et al., 2013). Some efforts have been made to integrate interprofessional education into child welfare (Gillespie et al., 2010;Marsh, 2006), though most of these efforts focus on partnering with health professionals rather than legal professionals. An exception to this gap can be found in the work of Faller and Vandervort (2007), who presented a model used at the University of Michigan for joint training of law and social work students. The field of child welfare might consider prioritizing and expanding these efforts with the goal of improving inter-professional communication in child welfare cases.
These results also have implications for practice at the administrative level. Just as administrators are encouraged to integrate the client voice into agency decision-making (Mizrahi et al., 2009), so too should administrators consider the input of case managers and guard against the suppression of their voices. Part of this involves the expectation that the agency's supervisors use management styles that are less directive and more democratic. Further, administrators have a responsibility to engage the funding agency to ensure that services recommended by case managers are funded.

Limitations and Implications for Research
These results should be considered in light of the study's limitations. Ideally, qualitative research is conducted with repeated rounds of analysis and consultation with the participants, resulting in continued refinement of the results. The present study lacked this iterative process, since the researchers had access to participants only through the focus group discussion. Another ideal condition in qualitative research is the presence of multiple methods of data collection to allow for triangulation. While the evaluation did involve multiple methods, this particular theme of voice suppression came directly from the case managers during the focus group discussions, which took place at the mid-point in the evaluation. The other methods were designed at the beginning of the evaluation and were of course guided by the goal of assessing the impact of the workforce initiative. Thus, suppression of the case managers' voice was not recognized as an important factor during the collection of quantitative data. However, the study did contain three separate focus groups, each of which spontaneously provided examples of voice suppression without being guided to do so. In this way, the repetition of narrative across the groups does provide some confidence in the conclusion that voice suppression is a common theme in the experience of the sample. Lastly, these results are specific to the sample in which they were collected, and therefore, lack generalizability to the population of case managers. The sample may have been composed of case managers who had particularly negative experiences with voice suppression that motivated them to participate in the focus groups. The degree to which these results represent the views of case managers in general is unknown.
Additional research is needed to further understand the perspectives of all professional partners and stakeholders in the child welfare field. Each narrative about one's experience in the system and one's view of interactions with others in the system can point to ways in which system functioning can be optimized. To extend this line of inquiry, this type of research with case managers should be replicated and similar research with other professional partners should be initiated. Important questions remain regarding legal professionals' perspectives on their role and the case managers' role, in addition to their preferences regarding inter-professional communication. Likewise, further research is needed in line with the work of Bogo and Dill (2008) on the experience of the child welfare supervisor, their perceptions of supervision management styles, and their perceptions of case managers.

Conclusion
This study contributes to the field's understanding of the case manager experience and the suppression of their voices. Too often, practice decisions and system reforms are structured by legislation that was developed without the consultation of those who directly experience the system. Likewise, the design of child welfare research is often shaped by forces at the macro level, including federal and state standards, administrators' agendas, and research funders' preferences. In order to shift this trend, the voices of case managers should be elicited, reported, and integrated into decision-making to guide child welfare research, child welfare system reform, and most importantly, child welfare outcomes.