The Journal of Applied

Behavioral Science
Volume 45 Number 3
September 2009 384-410

Civility, Respect, Engagement © 2009 NTL Institute

10.1177/0021886309335067

in the Workforce (CREW) http://jabs.sagepub.com

hosted at
http://online.sagepub.com
Nationwide Organization Development
Intervention at Veterans Health Administration
Katerine Osatuke
Scott C. Moore
Christopher Ward
Sue R. Dyrenforth
Linda Belton
Veterans Health Administration National Center for Organization Development

This article presents a description and preliminary evaluation of a nationwide initiative

by the Veterans Health Administration (VHA) called Civility, Respect, and Engagement
in the Workforce (CREW). The goal of CREW is to increase workplace civility as
assessed by employee ratings of interpersonal climate in workgroups. Once endorsed
by the VHA leadership and adopted by the leaders of particular VHA hospitals, CREW
was conducted by local facility coordinators who were trained and supported by the
VHA National Center for Organization Development. This article explains the concep-
tual and operational background of CREW and the approach used to implement the
initiative, presents results from two CREW administrations with a total of 23 sites, and
reports significant preintervention to postintervention changes in civility at interven-
tion sites as compared to no significant changes at comparison sites within each admin-
istration. It discusses these findings in the conceptual (theoretical) and operational
(intervention evaluation) context of interventions targeting civility.

Keywords: civility; organization development; intervention evaluation; survey feedback

T his study presents results from a nationwide organization development initiative

in the Veterans Health Administration (VHA), which focused on increasing
civility in the workplace. The initiative is called Civility, Respect, and Engagement
in the Workforce (CREW). We present the conceptual and operational background
of CREW, explain the approach that the VHA used to implement it, share initial
results, and discuss these findings in the theoretical and operational context of inter-
ventions targeting civility. In the CREW framework, and in this article, civility refers
to courteous and considerate workplace behaviors within the workgroup (the group
of people who work together and report to the same supervisor). More specific dimen-
sions understood to express civil behavior are coworkers’ personal interest and respect

384
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   385

toward each other; coworkers’ cooperation or teamwork; fair resolution of conflicts; and
valuing of differences among individuals, both by coworkers and by the supervisor.

Civility: Conceptual and Research Background

Civility generally refers to interpersonal behaviors that demonstrate respect and
“love of thy neighbor” (Anderson & Pearson, 1999). It builds on interpersonally
valuing and being valued by others—a concept that has long been theoretically rec-
ognized as important in the organization development and industrial–organizational
psychology fields (cf. Adlerfer, 1972; Herzberg, Mausner, & Snyderman, 1959; Likert,
1961; Maslow, 1973). Whereas particular civility norms vary among cultures and
work environments (Hartman, 1996), the importance of observing the shared norms
is universally recognized and even considered a moral virtue (Anderson & Pearson,
1999). Recent research into organizational outcomes highlighted that civility may
have not only moral but monetary value (Mohr et al., 2007; Moore, Osatuke, &
Howe, 2008; Nagy, Warren, Osatuke, & Dyrenforth, 2007; Osatuke & Dyrenforth,
2006; Osatuke, Dyrenforth, & Belton, 2008).
Our contention is that civility constitutes an important part of the organizational
climate perceived by employees, and as such, civility influences important organi-
zational outcomes. Several meta-analytic studies have established the predictive
strength of organizational context variables and, in particular, employee percep-
tions of organizational climate for many crucial individual-level job outcomes
(Carr, Schmidt, Ford, & DeShon, 2003; Johns, 2006; Parker et al., 2003).
Individual outcomes accumulate to shape organization-level outcomes (Kopelman,
Brief, & Guzzo, 1990; Ostroff, 1992); this is the mechanism whereby psychologi-
cal outcomes, such as satisfaction, become organizational, such as turnover and
absenteeism. For example, one meta-analytic investigation (Harter, Schmidt, &
Hayes, 2002) used the data from 42 studies to show that business–unit–level
employee satisfaction relates to business outcomes including organizational per-
formance and costs. These findings support the organizational relevance of
employee workplace perceptions and call for closer attention to assessing and
monitoring the status and impact of organizational climate variables. One aspect
that has not been extensively examined but has strong theoretical support for its
connections with outcomes is workplace civility.
In health care, assessing the status, organizational effects, and mechanisms to
increase civility may be especially important. Health care employees are the main
vehicle whereby patient services are delivered, and the highly demanding emotional
drain of interacting with clients puts them at risk for burnout (Cordes & Dougherty,
1993), which, in addition to personal costs to health care employees, has severe
negative effects on patient care and satisfaction (e.g., Garman, Corrigan, & Morris,
2002). The organizational climate of respect, on the other hand, is inversely related
to burnout—an influence that has been found statistically significant beyond the
386   The Journal of Applied Behavioral Science

contributions of job demands and employee personality traits (Ramarajan & Barsade,
2006). Civility levels relate to important organizational outcomes in health care. For
example, respect was found to affect nurses’ trust in management (Laschinger &
Finegan, 2005), whereas perceived disrespect influenced both intentions to quit and
employees’ actual turnover (Pinel & Paulin, 2005). Also, teamwork culture in hos-
pitals (which is conceptually close to civility as we defined it) was reported to have
a significant positive association with patient satisfaction for inpatient care (Meterko,
Mohr, & Young, 2004).
Promoting civility at the workplace may be best conceived at the organizational
rather than purely individual level. This is because (in)civility may be thought of as
an interactive process occurring within a situational context (whether a workgroup
or entire organization) rather than single static events between separate individuals
(Pearson, Andersson, & Porath, 2005). For example, employee-perceived organiza-
tional support has been found to moderate the effects of psychological aggression
(i.e., extreme instances of incivility) on employees’ emotional well-being and job-
related affect (Schat & Kelloway, 2003). Workgroup incivility has been found to
have impact on job satisfaction and mental health over and above the impact of
personal incivility (Lim, Cortina, & Magley, 2008). This supports the relevance of
employee perceptions of the larger organizational culture to individual-level out-
comes of uncivil behaviors directed at employees.
The organization development (OD) field is based on the premise that organiza-
tions have the potential to change how employees experience their workplace. For
example, enhancing a positive social environment within an organization (effective
communication, autonomy, participation, and mutual trust) is believed to increase
employee satisfaction and positive attitudes (Argyris, 1964; Likert, 1961). Studies
evaluating effectiveness of specific interventions targeting employee perceptions of
organizational climate are, nevertheless, rare. With the important exception of Krebs’s
(1976) work, we are not aware of any studies that examined best practices of manag-
ing (in)civility at the workplace. This remains an important agenda for OD research
in general (Hutton, 2006) and in health care settings in particular.

Focus on Civility Within VHA: Organizational Background

The National Leadership Board of the VHA recently endorsed civility as a core
characteristic of an ideal workplace, prompted by several internal operations studies.
First, a survey of former employees who voluntarily left the VHA (Sirota Consulting,
2001) showed that across all job functions employees terminated for similar reasons.
From these employees’ perspective, key areas in need of attention included a lack of
respect and fairness and limited chances to express one’s ideas and become involved
in improving work processes. Another VHA study assessed rates of verbal abuse
among its employees using the same instrument as in the U.S. Postal Service Survey,
and it identified 67% of respondents exposed to verbal abuse in VHA (Hodgson
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   387

et al., 2004), compared to 37% in the Postal Service (Goldstein et al., 2000).
Coworkers (supervisors, coemployees, and subordinates) perpetrated between 15%
and 35% of verbal abuse incidents and were the next most frequent perpetrators after
patients. These results highlight the rates of verbal abuse (that is, extreme instances
of workplace incivility) and a need to address it. The VHA Stress and Aggression
Workgroup (Kowalski, Harmon, York, & Kowalski, 2003; Yorks, Neuman, Kowalski,
& Kowalski, 2007) examined how workplace stress and aggression affected employ-
ees’ and veterans’ satisfaction, service quality, and costs, and it suggested an inter-
vention approach fostering an interpersonally respectful environment. Local action
teams at 11 sites collected survey data and planned and conducted site-specific inter-
ventions based on the results. Compared to 15 control sites, follow-up assessment
showed significantly greater work climate improvement postintervention. More
positive perceptions of work climate were also associated with reduced aggression
and stress and better employee satisfaction and business results (Equal Employment
Opportunity complaints, violence claims, sick leave, overtime, patient waiting time).
These findings suggest that site-tailored interventions at the VHA, with the general
goal of promoting respectful environment, successfully addressed interpersonal work
climate problems.
Collectively, these studies establish that the organizational culture of interpersonal
interactions, specifically civility norms, have a steady relationship to individual-level
outcomes in the VHA (work motivation, absenteeism, turnover) and the VHA orga-
nizational mission (clinical care and patient satisfaction). These results suggest a
new direction of enhancing organizational performance that could be implemented in
the current Zeitgeist of tight budgets, heightened accountability, and increased focus on
performance measures. Casting civility as a crucial component of the workplace
reflects a heightened focus on workplace culture development as a strategy for
improving quality of the VHA’s processes and services. This focus resulted in the
nationwide CREW initiative within the VHA, with the primary goal to change orga-
nizational culture toward increasing workplace civility.

The CREW Intervention Model

The goal of CREW was to be accomplished by supporting work units as they
identify their strengths and areas for improvement with regard to civility. The mech-
anism of change believed to be at work during CREW interventions is that, for the
intervention period, the VHA organizations commit to giving time, attention, and
support to having regular (weekly) workgroup-level conversations about civility.
This understanding of what causes change reflects the client-centered roots of OD
(Herzberg et al., 1959; Maslow, 1973; Rogers, 1977), where the client’s motivation
is considered to be the main driver of change and clients’ own beliefs and percep-
tions (e.g., regarding what needs to be improved and what will constitute improve-
ment) are taken as an optimal guide for direction. The practitioner’s role is to help
388   The Journal of Applied Behavioral Science

clients clarify their current situation, needs, and motives and discover their capacity
to make choices. The practitioner does this by supporting the client’s focus on their
own thinking and planning process; that is, the facilitator does not articulate the
needs, define directions, or devise plans on behalf of the client. The practitioner’s
contribution to change is providing conditions for the client’s own work, that is,
making room (committing time, space, and resources to weekly discussions of work-
place civility) and offering interpersonal support (positive attitude, sincere interest,
active listening, ability to relate to the client’s perceptions; cf. Rogers, 1959). To sum-
marize, much as in classic client-centered counseling (Bozarth, 1999; Rogers, 1959),
the practitioner helps organizational clients design their own intervention and sup-
ports them as they carry it through.
This approach, rather than providing any specific structure or ingredient of inter-
vention, is viewed as a critical feature that causes increases in civility as a result of
CREW interventions. Across the sites, the specifics of in-group process and follow-
ups are allowed to vary greatly, and as a result, the interventions become driven by
responsiveness to local needs and local culture-based civility definitions. Conceptually,
this is based on the premise that, as interventions proceed, clients’ needs and percep-
tions often change or become redefined. This conclusion, well established in the OD
field (Armenakis & Zmud, 1979; Golembiewski, Billingsley, & Yeager, 1976; Millsap
& Hartog, 1988), is taken into account by process-oriented OD approaches of which
CREW is one. The main distinguishing feature of successful interventions in the
CREW framework is their “responsive” (flexibly adjusting to the changing contexts
and new needs that emerge on a moment-to-moment basis) rather than “ballistic”
(fully planned and specified in advance, as prescribed by intervention theories or
practice manuals) nature (Stiles, Honos-Webb, & Surko, 1998).
The importance of responsiveness over any specific intervention ingredients is
supported by process-outcome research in other fields (e.g. counseling, psycho-
therapy). For example, correlations between outcomes and certain types or elements
of interventions overwhelmingly yield null findings (Beutler, 1991; Elliott, Stiles, &
Shapiro, 1993; Luborsky, Singer, & Luborsky, 1975; Stiles, Shapiro, & Elliott, 1986).
A lack of a connection between outcomes and specific intervention types or ingredi-
ents has been documented in OD research as well (e.g. Porras, 1979), which we
believe supports the argument for the crucial importance of responsiveness of inter-
ventions, although studies evaluating effectiveness of OD interventions on work-
place climate change remain rare.
The CREW initiative thus represents a customized and flexible intervention app­
roach, whereby each site chooses its specific definitions and areas of focus related to
civility. Whereas this strategy optimizes local autonomy and adaptability of the inter-
ventions and, we believe, drives the success of the interventions, it also clearly creates
additional challenges for systematizing and summarizing the results for research
purposes. To make the CREW interventions comparable across sites, preintervention
and postintervention assessments of workgroup civility climate relied on survey data
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   389

(the civility measure used is explained in the Method section). Beyond the research
purposes of examining civility outcomes for intervention and comparison sites, the
data were also used to capture and present a picture of the participating workgroups’
preintervention civility levels. The survey feedback provided an objective basis to
inform their subsequent discussion of what civility means for the group and which
aspects of workplace climate they want to improve. This use of survey data is a typi-
cal and recommended one in the context of OD efforts (e.g., Nadler, 1977).

CREW and the Prototype Model

To translate the notion of responsiveness into how it was specifically imple-
mented in CREW, consider another conceptual perspective provided by research on
prototypes as design tools for organizational change, specifically in health care (e.g.,
Banathy, 1996; Coughlan, Suri, & Canales, 2007; Weick, 2001). Although the CREW
approach was not designed with the prototype model in mind, the two models paral-
lel each other closely: Descriptions of how to use prototyping to facilitate organiza-
tional change in health care are very consistent with how CREW interventions
proceed. The following aspects are similar between the two models.
With respect to conceptualizing the intervention mechanism, the prototype-based
approach emphasizes connections between individual behaviors and their context
(workplace environment) and suggests the importance of redesigning the context to
shape the behavior. The same assumption (workplace behaviors are contextually
defined) is made within the CREW approach, with the same implication that attend-
ing to workplace environment is an important direction of change.
With respect to the intervention process, the prototype approach specifies that
employees first generate ideas to support specific organizational goals. In CREW,
this happens as well (usually at the first meeting); employees generate ideas of how
to increase civility of workplace interactions, which represents the specific organi-
zational goal of CREW. The next step, in the prototype model, involves collecting
and sharing data on workplace perceptions, employee, and customer behaviors to
clarify areas of strength and opportunities for improvement. This step also applies to
CREW and occurs at the first meetings at the sites.
With respect to facilitative tools used within interventions, in the prototype model
as well as in the CREW framework, ideas on how to support the goals of change are
brainstormed and translated into concrete, easy-to-grasp, visually friendly expressions
(such as sunny or stormy weather icons to express the daily interpersonal climate in
the workgroup). These visual expressions serve as reminders of the group’s focus and
help monitor progress. In the prototype model, such tools are called prototypes—
tangible expressions of ideas that are made quickly from inexpensive, accessible mate-
rials that serve to provide immediate, concrete feedback mechanisms for facilitating
organizational thinking. In CREW, most of the assessment instruments in the interven-
tion tool kit (described later in the Method section) can be thought of as prototypes.
390   The Journal of Applied Behavioral Science

Another common feature is flexibility of the intervention focus: In both models,

the focus is explicitly allowed to shift, reflecting the changing needs of the users. In
the prototype model, the foci for specific desirable changes suggested by prototypes
do not stay rigid throughout the intervention but are meant to evolve, reflecting
organizational learning. This is similar to the CREW concept of responsive, not bal-
listic interventions. Furthermore, in the prototype model, the evolving nature of
prototypes creates a higher-than-traditional degree of collaborative involvement from
the intervention users. Intervention tools thus become influenced and shaped by the
users’ experience that the consultants do not necessarily possess. As the employees
collectively redesign the prototypes and reality-test their improved understandings
of new behaviors represented by the prototypes, further experimentation is encour-
aged, failures are allowed, and feedback processes are used extensively. These same
processes (growing employee engagement in designing their own interventions and
consequent ongoing redesign of the foci and tools) also happen during the CREW.
Throughout the CREW intervention, employees at participating sites actively rede-
fine the tools to reflect their local culture and changing needs and foci of the inter-
vention. Recognizing the crucial importance of incorporating user experience in
organizational change processes, including specifically in health care, is consistent
with extant OD thinking (e.g., Bate & Robert, 2007; Bragg & Andrews, 1973;
Weick, 2001). In the CREW approach as well as in the prototype model, testing
various alternatives against the requirements and constraints of the local culture
helps employees learn faster what works and what does not. In this process, ideas
with promise, and tools that express them, become elaborated and further dissemi-
nated in the workplace, and ideas and tools that do not work are discarded. In
CREW, the results are interventions that share the same goal (increasing workplace
civility) across all participating sites where particular intervention methods are cus-
tom adapted by the local users. Shared and site-specific elements of the interventions
are discussed in more detail in the Method section.

CREW Within the VHA: Operational Context

The overarching framework for the CREW approach that was endorsed by the
VHA National Leadership Board is as follows. Providing organizational support for
consistently civil workplace behaviors (the first element) is expected to affect work-
place perceptions, resulting in employees’ feeling respected and empowered to act
(the second element). This, in turn, is expected to influence employee actions within
the organizational context evidenced by an increase employee engagement (defined
as collaborative efforts toward VHA goals)—the third element. These expectations,
based on the National Leadership Board’s interpretation of results from internal stud-
ies, are generally consistent with the directions of previous OD thinking (e.g., Ostroff,
1992) and extant research (e.g. Laschinger & Finegan, 2005), and they represent a
broad operational context for CREW.
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   391

The CREW initiative, and its evaluation in this article, focuses specifically on the
first element of these expectations: civility. This study is based on the data from the
first two administrations of CREW. We compared VHA employees’ civility ratings
before and after their workgroups participated in CREW. We contrasted these results
with comparison groups that did not participate in CREW and concluded that the
civility-focused CREW intervention was successful overall. Additionally, we describe
our approach to devising and implementing CREW interventions, discuss strengths
and limitations of this approach, and make suggestions for further research on inter-
ventions targeting workplace civility.

Method

Participating Sites
The two CREW administrations examined here (we will refer to them as CREW-1
and CREW-2) included VHA facilities from all over the country of all sizes and
structural complexity (e.g., small, rural hospitals and large, urban facilities in met-
ropolitan areas). Preintervention and postintervention tests were included within
each administration. Eight facilities, one workgroup each, participated in CREW-1;
six of these could be matched to comparison groups and were, therefore, retained in
final analyses. Thirty-eight workgroups from 20 facilities, from 1 to 5 workgroups
each, participated in CREW-2. Of these, 17 workgroups were retained in final
analyses because they satisfied two conditions: They had at least 10 participants in
both the preintervention and postintervention surveys and also could be matched to
comparison groups. Staff members in participating workgroups had moderately
diverse professional backgrounds (e.g., clerks, secretaries, and administrative super-
visors) but were all part of the same service (e.g., administrative personnel, clinical
care providers, pharmacy). Professional background and facility characteristics were
similar for comparison groups and their matched intervention groups. Demographic
background of comparison groups was not systematically different from VHA over-
all and represented a variety of gender, age, length of organizational tenure, and racial
characteristics. Demographic background of intervention groups was not assessed
for operational reasons (to avoid creating a perception that individual participant
identities within small CREW groups will be focused on). However, there is no
reason to believe that demographic background of intervention groups systemati-
cally differed from comparison groups and VHA overall.

Intervention Procedure
Local facility coordinators conducted the CREW intervention with the support
and coordination of the VHA National Center for Organization Development (NCOD).
Implementation of the CREW framework at the facilities was shaped by two major
392   The Journal of Applied Behavioral Science

influences: (a) the NCOD practice model that summarizes NCOD usual strategies of
conducting organizational consultation and intervention and (b) the local workplace
culture. NCOD made the same educational kit available to each site; its elements
were selected and used at the local facilitators’ discretion.

NCOD practice model. The NCOD practice model is process consultation

(Reddy, 1994; Reddy & Phillips, 1992; Schein, 1988, 1990, 1992, 1999, 2006), with
strong influences of action science and action inquiry (Argyris, Putnam, & Smith,
1985; Argyris & Schon, 1974, 1978, 1996; Torbert, 1989, 1991a, 1991b). The client
is seen as a subject matter expert. The practitioner brings in expertise about human
and organizational processes and about facilitation of the client’s actions. The client
is a decision maker, responsible for owning, planning, and implementing change.
The practitioner clarifies the client process, highlights resources and options avail-
able, supports local leaders, trains local facilitators, and uses professional expertise
on interpersonal and systemic processes and client assessment data as sources of
information and feedback to the client. Organization development is a data-based
activity (Harvey & Brown, 1992; Nadler, 1977), and while facilitating CREW, NCOD
routinely uses instrumentation to generate data that clients then use for assessing the
situation, interpreting current needs, and planning actions.
NCOD practitioners provide overall resource coordination, a tool kit of educa-
tional activities, and opportunities to exchange experience among CREW facilities.
They act as process consultants to the local facility coordinators, for example, answer-
ing questions about meeting facilitation or sharing experience on working methods
from other sites that had similar environment or workplace issues. The practitioners
who facilitate CREW are all clinical or counseling PhD or PsyD psychologists with
postdoctoral OD training. They work as a team, valuing continuous learning from
clients and from each other. Consistent with the action science and action inquiry,
they adopt a multitheoretical approach to cases, which leads to joint conceptualiza-
tions of interventions through a consensus-building process. Like all of NCOD
work, CREW is based on involving all employees in the organization (i.e., all mem-
bers of participating workgroups). The interpersonal relationship is understood as
the core of intervention and action planning. Consequently, the local conversation
about civility is given top priority, as opposed to implementing models and direc-
tives brought from the outside.

Local influences. Local workplace culture is considered crucial to capture during

CREW implementation. The literature describes incivility as unique to particular
situations (e.g., Hutton, 2006). Similarly, the CREW approach conceptualizes civil
behaviors as culturally specific to each organization; a rural, Midwestern hospital
and a large, urban New York facility may each define civility differently. Incorporating
local culture into each CREW intervention was, therefore, considered vital to suc-
cess. This created variation among sites’ definitions of civility, intervention foci, and
strategies.
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   393

Shared aspects of CREW intervention. The NCOD intervention approach shaped

shared elements in defining civility across the sites. Civility is defined as workplace
behaviors. Civil behaviors are seen as impersonal, displayed on behalf of the orga-
nization, and are directed toward everyone at the workplace, not exclusively towards
people with whom one has a personal relationship. Civility is understood as based
on awareness of one’s interpersonal impact; people monitor their own behavior dur-
ing specific interactions with others and pay attention to how others receive it. More
specific contents of civil workplace behaviors are defined locally and thus vary across
sites.
Shared aspects of the CREW intervention process across sites are as follows.
NCOD trains local CREW leaders from each site by explaining the rationale for
CREW and its operational background and sharing the data in support of the orga-
nizational relevance of civility. A preintervention survey is conducted using the
civility scale. Based on preintervention survey scores and/or the tools within the
educational kit that they see as fitting their needs, each site chooses specific areas of
foci related to civility. For example, some sites (often those with low pretest scores)
devote much time to discussing their definition of civility and respect and focusing
on improving basic communication between participants. Others (with higher initial
scores of civility) focus on extensive sharing about their backgrounds and deepening
workplace relationships. Some sites also develop actions supporting greater collabo-
ration toward employees’ shared work-related goals. CREW coordinators lead inter-
ventions at their facilities by facilitating regular on-site meetings. At the meetings,
baseline data on civility are first shared and discussed within workgroups. The work-
groups then decide which actions to take to improve their overall civility, thus devel-
oping their own methods for improving their work environment. Six-month follow-up
assessment is conducted using the same civility scale. As additional support to the
sites, NCOD offers and facilitates pilot meetings and monthly conference calls for
all local coordinators.

Educational tool kit. NCOD shares with each site the same educational tool kit
containing ideas and experiential activities that promote exploration of CREW com-
ponents. Appendix A lists the items included in the tool kit.

Measures
Civility levels at the participating sites were measured by an 8-item civility
scale (Meterko, Osatuke, Mohr, Warren, & Dyrenforth, 2007, 2008). The scale
measures aspects of workplace civility through employee ratings of personal inter-
est and respect from coworkers, cooperation or teamwork in the workgroup, fair
conflict resolution, and valuing of individual differences by coworkers and super-
visor. The civility scale is a group of items originating from the voluntary, anony-
mous VHA All Employee Surveys (AES), administered in 2004 and 2006 and
394   The Journal of Applied Behavioral Science

yearly thereafter. These items belong to one of the three parts of the AES: the
Organizational Assessment Inventory (OAI), made of questions where respondents
rate particular characteristics of their workgroup climate. The OAI was composed
by the Office of Personnel Management at the Federal Human Resource Agency
(Gowing & Lancaster, 1996) on the basis of two sources: their pre-existing survey
(available at https://www.opm.gov/surveys/services/OrgAssessSurvey.asp) and the
Generic Stress instrument used by the National Institute for Occupational Stress
and Health (Hurrell & McLaney, 1988).
In the exploratory and confirmatory factor analyses of the OAI data in 2004
(Meterko et al., 2007, 2008), the group of items that later formed the Civility scale
showed high consistency in their loadings on a single factor, interpreted to reflect the
concept of civility. Item-to-scale correlations ranged from .67 to .83 for the eight
items; Cronbach’s alpha for the scale was .93. This group of items was used in the
AES without modifications in all subsequent years. In VHA internal operation stud-
ies, an index score based on this group of items has shown statistically significant
hospital-level relationships to employee absenteeism and turnover and to indepen-
dent measures of patient satisfaction. These relationships, the content of the items
that had face validity for VHA stakeholders, and endorsement of the civility concept
by the VHA leadership contributed to a wide use of the civility scale within the VHA
organizational culture, and eventually prompted its choice as a preintervention and
postintervention measure for the CREW initiative.
The Civility scale items with their labels are listed in Appendix B. For each respon-
dent, a single index of workgroup civility was computed as an average of the 8 items.
A workgroup-level aggregate of the civility index was then used to measure work-
group civility. The scale provided quantitative data for comparing employee percep-
tions of organizational climate from preintervention to postintervention, and it allowed
for comparing CREW participants’ ratings to other VHA groups within the same
year. Internal consistency reliability for the scale was found to be high: Cronbach’s
alpha values for CREW-1 and CREW-2 were .93 and .94, respectively, consistent in
preassessment and postassessment surveys and also consistent with the VHA AES
data.

Research Design
The study included two administrations of CREW: CREW-1 and CREW-2.
CREW-1 included eight intervention workgroups, with 899 participants altogether.
Two workgroups, due to their unique occupational makeup, could not be matched to
any comparison groups and were excluded from the analyses. This left six interven-
tion workgroups (participants’ n = 425 pretest and n = 328 posttest altogether),
matched to six comparison workgroups (participants’ n = 236 pretest and n = 407
posttest). CREW-2 included 38 workgroups, with 1,295 participants altogether.
Of those, 26 workgroups had 10 or more respondents on both preintervention and
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   395

postintervention surveys, and 17 of these 26 workgroups could be matched to com-

parison groups (the other workgroups could not be matched due to their unique
occupational makeup). This left 17 intervention workgroups (participants’ n = 688
pretest and n = 647 posttest), each matched to a comparison workgroup (total par-
ticipants’ n = 607 pretest and n = 680 posttest). Civility ratings compared from
preintervention to postintervention came from the CREW surveys, for intervention
workgroups, and from the matching years’ AES data for comparison groups.
The Civility scale for CREW preintervention and postintervention surveys was
administered at CREW-1 participating sites in September 2005 and July 2006, respec-
tively, and at CREW-2 sites in February 2006 and March 2007, respectively. For
operational reasons reflecting VHA data security and confidentiality procedures,
matching individual CREW participants’ ratings from preintervention to postinter-
vention surveys was impossible: Respondents had to be identified by their work-
group ID only, not by their individual ID. Therefore, although individual ratings were
available and were used in the analyses, preintervention to postintervention scores
were comparable at the workgroup level only. Because the scale items clearly refer-
ence workgroup climate, the preintervention and postintervention ratings still mea-
sure the same referent for members of the same workgroup. Score changes are therefore
interpreted as workgroup-level changes in civility climate.
Control sites that did not participate in CREW but had participated in the VHA
AES in May of 2004, 2005, and 2006 were retrospectively matched to intervention
sites within the respective years. Preintervention comparison sites’ data for CREW-1
were from the 2004 AES administration and the postintervention data for the same
sites came from the 2005 AES data. For CREW-2, preintervention comparison site
data came from the 2005 AES administration and the postintervention comparison
data came from the 2006 AES administration for the same groups. This strategy
reflects nonequivalent control group design (Campbell & Stanley, 1963), a quasi-
experimental design used when random assignment to groups is impossible, whereby
compared groups are assembled naturally rather than experimentally. Given this
design, attributing groups’ differences on the posttest to group differences in inter-
vention status (i.e., to whether they had or did not have CREW) assumes similarity
in all other characteristics of intervention and comparison groups. To ensure such
similarity, we matched intervention sites and comparison sites by two criteria: occu-
pations within workgroups (e.g., nurses, human resource specialists, clerks) and
organizational complexity of the hospitals. The latter included five complexity cat-
egories used in the VHA system based on (a) patient volume, (b) patient risk level,
(c) number of clinical specialties and patient services, and (d) amount of teaching
and research done at the hospitals. Whenever available, the match also incorporated
a third criterion: geographic proximity. Similarity between intervention and com-
parison groups was further confirmed by comparing their pretest scores.
396   The Journal of Applied Behavioral Science

Data Analyses
A random effects two-by-two univariate analysis of variance (ANOVA), with
an alpha level of .05, was used to examine differences in civility index scores for
intervention and comparison sites as a function of survey time (preintervention or
postintervention). We considered individual-level data, first from both administra-
tions of CREW together and then separately for each CREW administration. That is,
we first compared civility scores from all CREW intervention sites within both
CREW administrations to civility scores from all of their respective matched com-
parison sites. Then we used the same approach to compare all intervention sites to
all comparison sites within CREW-1 only. Finally, we compared all intervention to
all comparison sites within CREW-2 only. This approach, rather than comparing
single intervention to single comparison groups site by site, was chosen because
many CREW sites had small numbers of participants and would, therefore, yield
little statistical power to detect differences.

Results

We found significant group differences in civility levels only between interven-

tion sites. As expected, at these sites only, ratings of workplace civility increased
from preintervention to postintervention, whereas at the comparison sites, civility
levels remained stable across time. In other words, the only factor associated with
significant differences in civility was the interaction term (intervention by time): that
is, the combination of intervention status (did or did not participate in CREW) and
survey time (preintervention or postintervention). Main effects of time (comparing
civility ratings across time while examining intervention and comparison sites all
together) and main effects of intervention status (comparing intervention to com-
parison sites while considering their preintervention and postintervention ratings all
together) were not significant. The nonsignificant main effect of time suggests there
were no changes in civility levels at the sites that would be due only to the different
survey timing (preintervention versus postintervention). That is, timing of the survey
alone did not make the difference in reported civility levels; the combination of
intervention and survey timing did. The nonsignificant main effect of intervention
status suggests there were no differences in civility levels that would be due only to
the sites’ membership in the intervention group versus the comparison group. That
is, civility levels at intervention sites were not overall different from those at com-
parison sites, unless we consider the timing of civility measurement (preintervention
versus postintervention). These results speak to the main point of this evaluation:
They allow us to ascertain that CREW participation is associated with significant
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   397

Table 1
ANOVA Tests of Between-Subject Effects for Civility
Scores for CREW-1, CREW-2, and Overall
Source SS df MS F η

CREW-1
Intervention status 59.92 1 59.92 5.89 0.85
Time 3.96 1 3.96 0.39 0.28
Status × Time 10.17 1 10.17 11.87** 0.01
Error 1192.45 1392 0.86
CREW-2
Intervention status 1.81 1 1.81 0.42 0.29
Time 14.54 1 14.54 3.34 0.77
Status × Time 4.35 1 4.35 4.42* 0.00
Error 2573.00 2618 0.98
Overall
Intervention status 13.50 1 13.50 1.06 0.51
Time 14.83 1 14.83 1.16 0.54
Status × Time 12.73 1 12.73 13.35*** 0.00
Error 3828.62 4014 0.95

Note: CREW = Civility, Respect, and Engagement in the Workforce. Intervention status consists of CREW
participants and equivalent comparison groups. Time consists of preintervention and postintervention.
*p < .05. **p < .01. ***p < .001.

improvement in civility ratings after the intervention and that the CREW interven-
tion is what causes these improvements. The next subsection presents the specific
findings, first reporting them for the overall sample and then breaking down into
CREW-1 and CREW-2 administration.

ANOVA Results
Examining all CREW data together (Table 1) showed that differences in civility
index scores were not significant for main effects of the intervention status (inter-
vention or comparison site) and for main effects of the survey time (preintervention
or postintervention survey). The interaction term (intervention status by survey time)
showed significant effects, F(3, 4014) = 13.35, p < .001. The overall intervention
sites’ mean increased from 3.459 (SD = 0.99) at preintervention to 3.695 (SD = 0.93)
at postintervention, whereas the overall comparison sites’ mean remained stable:
3.456 (SD = 1.00) at preintervention and 3.465 (SD = 1.01) at postintervention.
Examining CREW-1 data only showed the same pattern: Differences in civility
index scores were not significant for main effects of the intervention status (inter-
vention or comparison site) and survey time (preintervention or postintervention).
The interaction term (intervention status by survey time) showed significant effects,
F(3, 1392) = 11.87, p < .001. The overall intervention sites means increased from
398   The Journal of Applied Behavioral Science

Figure 1
Mean Changes for the Intervention and Comparison
Sites for CREW-1 and CREW-2

3.9

3.8

3.7
Civility Scale Mean

3.6
CREW-1 Intervention Sites
3.5 CREW-1 Comparison Sites
CREW-2 Intervention Sites
3.4 CREW-2 Comparison Sites

3.3

3.2

3.1

3
Pre-survey Post-survey
Time

Note: CREW = Civility, Respect, and Engagement in the Workforce.

3.641 (SD = 0.85) at preintervention to 3.956 (SD = 0.77) at postintervention,

whereas the overall comparison sites means remained stable: 3.390 (SD = 1.03) at
preintervention and 3.324 (SD = 1.04) at postintervention.
Examining CREW-2 data only showed the same pattern again: Differences in
civility index scores were not significant for main effects of the intervention status
(intervention or comparison site) and survey time (preinterevention or postinterven-
tion). The interaction term (intervention status by survey time) showed significant
effects, F(3, 2618) = 4.42, p = .05. The overall intervention sites means increased
from 3.347 (SD = 1.01) at preintervention to 3.578 (SD = 0.98) at postintervention,
whereas the overall comparison sites means showed no significant change: 3.481
(SD = 0.99) at preintervention and 3.549 (SD = 0.99) at postintervention.
Figure 1 shows estimated marginal means for CREW-1 and CREW-2, obtained
by the 2 × 2 ANOVAs reported above. Figure 1 illustrates significant differences
between preintervention and postintervention scores for intervention sites only but
not for comparisons within both CREW administrations. Figure 1 also shows how
the pattern of change for the intervention and comparison sites was different for
CREW-1 and CREW-2.
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   399

Figure 2
Mean Changes for the Intervention and Comparison Sites for All CREW
Interventions With National VHA Civility Mean Across 3 Years

3.75

3.7

3.65

3.6
Civility Scale Mean

3.55 CREW Overall Intervention Sites

CREW Overall Comparison Sites
3.5 VHA Civility Mean 2004-2006

3.45

3.4

3.35

3.3
Pre-survey Post-survey
Time

Note: CREW = Civility, Respect, and Engagement in the Workforce. VHA = Veterans Health
Administration.

Figure 2 summarizes results of CREW overall and compares them to VHA

national civility ratings as measured by the AES. The VHA mean for the civility
scale remained constant from 2004 to 2006 at 3.60. The difference between the
postintervention means and the VHA national average provides a context for evalu-
ating the impact of CREW and its operational implications.

Discussion

The purpose of CREW was to increase employee-rated workplace civility at the

participating sites. The main conclusion of this study is that this purpose was achieved,
as is demonstrated by significant improvement of employee civility ratings from
preintervention to postintervention surveys at sites that had the CREW intervention
but not at the comparison sites. These results support our conclusion of significant
400   The Journal of Applied Behavioral Science

improvement in perceptions of workplace civility post-CREW and lend evidence to

our claim that CREW interventions cause improvement in civility. Importantly, the
intervention sites as a group did not have overall higher civility levels than the com-
parison sites did; improvement in civility thus cannot be attributed to inherent char-
acteristics of these sites. Also, no changes in civility happened spontaneously over
time at comparison sites; significant improvement in civility at intervention sites
postintervention, thus, cannot be attributed to the passage of time alone. Together
these findings suggest that higher postintervention than preintervention civility ratings
at the intervention sites are due to their participation in the CREW intervention.
The anticipated by-products of CREW-targeted culture change were (a) employees’
conscious awareness of the importance of civility at the workplace and (b) employees’
understanding of a connection between acting civilly and effectively carrying through
the VHA mission (to provide excellent health services to the nation’s veterans). Post-
CREW qualitative data (written comments that CREW participants and facilitators
provided with their postintervention ratings) offer some evidence of an improved under-
standing of the business case for civility postintervention. Unprompted, respondents
endorsed connections between civility of workplace interactions and success in out-
comes of specific work-related tasks. Their comments suggested this heightened aware-
ness was a result of exposure to the information included in the marketing materials for
CREW and also of experiential-interpersonal learning as CREW participants.
It is noteworthy that both CREW administrations were overall highly successful
in increasing employee perceptions of a civil workplace. The CREW-1 sites were
those whose leaders volunteered to try a new initiative in the VHA system. Given
this reason for their self-selection into the intervention, these sites were collectively
above the VHA level of civility. Their overall results demonstrated that the CREW
intervention was able to bring their civility ratings even higher. The question of a
ceiling level (high civility baseline that remains unaffected by CREW) may have
been indicated by one of CREW-1 sites where the preintervention and postinterven-
tion ratings remained essentially the same. (This site was not included in the analy-
ses reported here because, due to its unique occupational makeup, we were unable
to find a matching comparison site for it.) In one participant’s comment provided
with postintervention ratings, this site had “Good CREW environment to start with.
Any CREW activities just supported what we already do.” On the other hand, unlike
CREW-1 sites, CREW-2 sites were collectively below the VHA mean on civility.
Their self-selection into the intervention likely illustrated the impact of success of
CREW-1 in the VHA system, which increased the visibility of the CREW initiative.
That is, facilities with lower civility levels appear to have joined CREW-2 in the
hopes to use CREW to remedy their known difficulties with workplace climate. This
raises a question to be further explored about whether there is a floor level for
CREW impact (a low civility baseline that remains unaffected by CREW).
Whereas the results of this study have addressed the question of evaluating suc-
cess of the CREW initiative overall, these results also raise new questions that merit
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   401

further examination as CREW data from new administrations accumulate. Variability

in postintervention civility ratings across intervention sites, particularly the best and
worst postintervention ratings, appears to be of most interest for future studies. This
variability is to be expected based on a number of potential factors that vary across
sites: for example, support of executive leadership, supervisors, unions, skills of facili-
tators, and issues within the workgroups. Additional differences may be found in
ways that sites make use of the resources offered to them: for example, extent and
the exact nature of contact with NCOD coordinators throughout the intervention,
reliance on particular elements within the tool kit rather than other elements, and so
forth. Because CREW aims at making full use of rather than eliminating the sources
of differences in intervention process among participating sites, addressing this vari-
ability by imposing a tighter structure onto the intervention process will not be pos-
sible. This poses a question, both for us and for others to ponder, about optimal strategies
for summarizing and evaluating an intervention that is unstructured by its very defi-
nition, as it is designed and redesigned by the participants themselves throughout its
entire course.
The main feature of CREW intervention is its extreme flexibility. Responsiveness
to local needs and local culture-based civility definitions is thereby maximized
and emphasized over any specific ingredient of intervention. This approach is
typical of process consultation models (Reddy, 1994; Reddy & Phillips, 1992;
Schein, 1988, 1990, 1992, 1999, 2006). It has been corroborated by process-
outcome research findings in OD (Porras, 1979) and in other fields (Larson & Yao,
2005; Stiles, 1988; Stiles et al., 1998). As one illustration, alliance, a contextual
factor reflecting participants’ interaction, has been found to predict intervention
outcomes better than any specific treatment component or technique (Blow,
Sprenkle, & Davis, 2007; Castonguay & Beutler, 2005; Marziali, 1984); and the
interpersonal relationship has been described as crucial in defining intervention
outcomes, even in nonpsychologically oriented treatments (Larson & Yao, 2005).
However, whereas the strategy of capitalizing on the variability of local needs and
cultures may underlie the success of CREW, it certainly creates additional chal-
lenges for systematizing and summarizing the intervention results for research
purposes. Also of note, substantial differences in site size may complicate statisti-
cal comparisons at the site level. Increasing sample size at the sites may help
prevent this potential problem for studies interested in comparing CREW interven-
tions across sites.

Limitations of This Study

This study was based on a quasi-experimental rather than true experimental design
(Campbell & Stanley, 1963) in which the compared groups were assembled natu-
rally: No random assignment of participants to groups took place. Intervention sites
were matched to comparison sites on two categories: occupational composition of
402   The Journal of Applied Behavioral Science

the workgroup and operational complexity of the hospital (the latter incorporated 4
separately assessed criteria). We believe this matching substantially increased simi-
larity between intervention and comparison groups; the similarity was further con-
firmed by absence of significant main effects for intervention status. A further limitation
of the group matching is nonequivalent time periods between preintervention and
postintervention surveys for the comparison groups. The CREW groups were tested
at 6-month intervals, whereas the AES data are available annually. This means a
12-month interval for comparison groups that did not occur at the same time as the
preintervention or postintervention surveys for the intervention groups. In spite of
the chronological mismatch, we feel the comparison groups adequately illustrate the
reality that civility does not spontaneously improve without intervention. We also
contend the incongruent survey time frames, 6 versus 12 months, do not present a
comparison issue because it is unlikely that civility ratings occur in an inverted U on
a 12-month cycle. Nevertheless, random preintervention assignment to intervention
or experimental condition, if it were possible, would provide stronger grounds for
our claim that postintervention changes were due to intervention, not to preexisting
differences between the intervention and comparison sites. The nonequivalent con-
trol group design used here appeared to be the best choice available, given that the
study took place within the working parameters of a functioning health care system.
Nevertheless, a replication of the study in pure experimental conditions would fur-
ther strengthen our conclusions.
Similarly, matching individual participants’ scores from pretest to posttest, if it
were possible, would enable paired samples analyses and thus provide stronger sta-
tistical grounds for evaluating significance of change from pretest to posttest. Within
this investigation, this option was not available given the boundaries and operational
parameters of the organizational system under study. Future studies would benefit
from overcoming this limitation.

Recommendations for Future Research

Variability in site characteristics and intervention processes across sites raises
questions about optimal ways of capturing this variability and systematically relat-
ing it to postintervention results. It appears that an optimal strategy may involve
measuring process variables (e.g., degree of involvement of participating work-
groups, facilitators, and supervisors as well as their extent of using NCOD staff as
consultants and resource) rather than any fixed set of site characteristics or interven-
tion elements. This strategy may help systematize variability in CREW processes
without artificially homogenizing the uniqueness of interventions and participating
sites. For example, levels of supervisors’ commitment to CREW may be a promising
predictor to evaluate. Previous studies found management commitment to proper
implementation to be essential for success of workplace interventions (Rodgers &
Hunter, 1991; Rodgers, Hunter, & Rodgers, 1993), although this predictor has not
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   403

been examined specifically for civility-targeting programs. Our preliminary findings

(Osatuke, Mohr, et al., 2008) suggest that a combination of workgroup supervisors’
and coworkers’ commitment to participating in the CREW process is an important
predictor of higher postintervention ratings of workplace civility and an even more
important predictor of postintervention perceptions of higher improvements in
workplace civility.
Alliance between the facilitators and participants may be also important to account
for in future studies. In therapy and counseling process-outcome studies, alliance
rather than any specific intervention technique has been repeatedly revealed as the
strongest predictor of treatment outcomes (Blow et al., 2007; Castonguay & Beutler,
2005; Marziali, 1984). Alliance, however, may also be thought of as an intermediate
outcome rather than a pure causal factor: For example, one cannot decide to use
“more” or “better” alliance when it is poor. Alliance is a product of other interpersonal
processes and behaviors in which both participants and facilitators engage over time.
These processes and behaviors may represent the causal factors that bring about both
alliance and positive intervention outcomes.
Evaluating the impact of CREW from the perspective of its recipients, including
their perception of the intervention itself and of the difference it made for them per-
sonally, appears a useful direction of subsequent research, qualitative or quantitative.
Participant experience is an important but typically understudied aspect of organiza-
tional change (Bartunek, Rousseau, Rudolph, & DePalma, 2006). CREW interven-
tion design makes such studies possible because it includes both qualitative data
(open-ended comments from participants, facilitators, and NCOD staff) and quanti-
tative data (preintervention and postintervention ratings of civility, comparable between
participating sites and also to the entire VHA, because the civility scale is part of the
annual VHA AES).
A viral spread metaphor was frequently used to describe CREW process at the
sites. This analogy captures how employees’ perception of civil treatment within the
organization may invite more prosocial behaviors and increased collaboration, result-
ing in higher perceptions of a civil organizational context, thus generating more proso-
cial behaviors and collaboration, and so forth. Whereas preliminary facility-level data
(e.g., Mohr et al., 2007; Nagy et al., 2007; Osatuke & Dyrenforth, 2006) are consis-
tent with the postulated connection between civility and organizational outcomes,
further studies of civility and its relation to workgroup-level outcomes (e.g. absen-
teeism, turnover) are needed and are now in progress at NCOD (e.g., Moore et al.,
2008; Osatuke, Dyrenforth, et al., 2008; Osatuke, Mohr, et al., 2008). To the extent
possible, future studies of civility in the field of health care should include patient
variables as well, for example, patient satisfaction and clinical outcomes. The concept
of an upward spiral of civility may also be usefully examined in parallel with the previ-
ously described concept, a downward spiral of workplace incivility (Pearson et al., 2005).
Our work in progress suggests these constructs may be related but nonoverlapping (Mohr,
404   The Journal of Applied Behavioral Science

Osatuke, Moore, Hodgson, & Warren, 2008); together, they may explicate the paths
whereby (in)civility affects employees and organizations.

Implications for OD Theory and Practice

The main implication for OD theory suggested by this study is the following.
Successful implementation of the CREW approach illustrated by this study within
VHA offers empirical support for the intervention model behind the CREW: the
process-oriented, responsiveness-based approach rooted in client-centered thinking
about organizational change. In terms of applications to practice, whereas CREW
interventions are flexible by design, shared aspects of the intervention process across
sites are sufficiently well defined and operationalized within the VHA CREW model.
To reiterate, these shared aspects are defined by the NCOD practice model and
include descriptions of coordinator and facilitator roles, educational tools made available
to all participants, and the VHA civility scale as a preintervention-to-postintervention
measure of change. A detailed account of these aspects offered in this article allows
for replication of the CREW approach in health care organizations other than VHA
and, more broadly, in other OD contexts.

Appendix A
Items Within the Educational Tool Kit
1. Suggestions for facilitators
(a) Successful facilitation tips, including an overview of facilitation skills, key points to
meeting planning, ideas for responding to disrespectful behavior, definitions of possi-
ble facilitator roles and expectations from workgroups, possible formats and ground
rules for workgroup discussions, templates of group sessions, ideas for follow-up, and
recommendations on how to encourage discussion.
(b) Possible questions for discussion of presurvey and any follow-up assessment, for
example, “What are we doing well? What are each of you individually doing that con-
tributes to that good score? What do we need to improve on? How could we use our
strengths to improve the lower scores? How could each of you individually have a
positive impact on these scores?”
(c) Suggestions about specific devices that workgroups could adopt to recognize CREW-
promoting behaviors. These include certificates of appreciation, CREW-In-Action
newsletters, buttons (“You’ve been caught doing the right thing and treating others with
civility and respect”), and lists of strategies for involving staff into reinforcing others
using these means.
(d) Experiential materials including lists and explanations of group activities, vignettes of
situations for problem solving in groups, and stories and metaphors for facilitators to
use in group discussions.
(continued)
 Osatuke et al. / Civility, Respect, Engagement in the Workforce (CREW)   405

Appendix A (continued)
2. Assessment instruments to be used at facilitators’ and workgroups’ discretion
(a) Visual tools for daily or weekly progress tracking, for example, CREW Daily Weather
Report kept at a location where staff gathers. It instills awareness of the workgroup
climate by expressing it through weather icons (from sunny to rainy or stormy). Each
employee rates the report at the end of the day by making dots or Xs; employees can
discuss these ratings the following day. Several sites reframed the tool as Pain Scale, a
metaphor they saw as more relevant to health care settings.
(b) Open-ended assessment tools, for example, sentence-completion forms: “I consider it
a great day at work when. . . . I feel appreciated when. . . . If I could change one thing
about my job, I would. . . . I know someone respects me when they. . . . The kind of
person that is hardest for me to deal with is. . . . I could be more productive in my work
if. . . . If people really listened to me, they would find out. . . .”
(c) Structured questionnaires evaluating areas of workgroup functioning, for example, an
Employee Recognition Survey Form elicits lists of behaviors seen as conveying appre-
ciation (“Please mark the top 5 ways you would like to be appreciated”). As another
example, a Management Feedback Survey invites confidential comments about work-
group leaders’ observable behaviors: those they were especially effective at, those they
could do better, and specific confidential feedback. Yet another example is an Initial
Team Effectiveness Assessment: “Please offer your candid opinion about your team by
rating it and your role along the scale below” (from 0 = never to 10 = always). The
scales include personal role (e.g., “I know what is expected of me at work”), team role
(e.g., “Communications between and among team members are open and two-way”),
and general team functions (e.g., “Team members regularly receive useful performance
feedback”).
3. Conceptual tools for facilitators and groups
(a) Summaries of key points of several psychological models of social behavior and its
determinants, for example, systems theories, Maslow’s (1973) hierarchy of needs, Lewin’s
(1948) force field analysis, and Berne’s (1996) transactional analysis of ego states—
parent, child, adult.
(b) Recommended popular literature on promoting and maintaining positive workgroup
climate, for example, Forni (2002); Covey (1990); Oakley & Krug (1994); Lundin,
Paul, Christensen, and Strand (2000); and Johnson and Blanchard (2002).
(c) Educational materials on group dynamics, for example, on conflict resolution, with an
overview of strategies and techniques; on the importance of rewarding desirable behav-
iors, with key points explained (defining and identifying desirable behaviors, timely
recognition, award mechanisms, clearly linking recognition to the behavior); and others.
4. CREW information such as the history of the initiative in the Veterans Health Administration
and civility business case materials (e.g., graphs of clinical and business outcomes associated
with high versus low civility ratings). The graphs make it visually obvious that higher civility
ratings at particular Veterans Health Administration facilities are associated with lower absen-
teeism, fewer equal employment opportunity complaints, higher scores on clinical perfor-
mance measures, lower turnover intentions of employees, and higher inpatient and outpatient
ratings of overall satisfaction with clinical care.
406   The Journal of Applied Behavioral Science

Appendix B
Veterans Health Administration Civility Scale
Q1 (Respect): People treat each other with respect in my work group.
Q2 (Cooperation): A spirit of cooperation and teamwork exists in my work group.
Q3 (Conflict Resolution): Disputes or conflicts are resolved fairly in my work group.
Q4 (Coworker Personal Interest): The people I work with take a personal interest in me.
Q5 (Coworker Reliability): The people I work with can be relied on when I need help.
Q6 (Antidiscrimination): This organization does not tolerate discrimination.
Q7 (Value Differences): Differences among individuals are respected and valued in my work
group.
Q8 (Supervisor Diversity Acceptance): Managers/Supervisors/Team leaders work well with
employees of different backgrounds in my work group.
Note: Item labels are in parentheses to distinguish from the actual item wording. Items were rated on a
Likert-type scale from 1 (strongly disagree) to 5 (strongly agree), with a middle option, Neither Agree
Nor Disagree. Do Not Know and Not Applicable options were available.

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Katerine Osatuke, PhD, is a staff psychologist at the Veterans Health Administration National Center for
Organization Development.

Scott C. Moore is a health scientist at the Veterans Health Administration National Center for
Organization Development.

Christopher Ward is currently self-employed as a practitioner of psychological services with a focus on

forensic practice.

Sue R. Dyrenforth is the Director of the Veterans Health Administration National Center for Organization
Development.

Linda Belton is the Director of Organizational Health for the Veterans Health Administration National
Center for Organization Development.