# The role of implementation climate in shaping early essential newborn care practice: Insights from a multi-center cross-sectional study in China

## TL;DR

This study shows that organizational climate, along with individual factors like knowledge and workload, significantly affects how well early newborn care practices are implemented in Chinese hospitals.

## Contribution

The study reveals that implementation climate indirectly influences EENC practices through its effect on attitudes, offering new insights into organizational barriers and solutions.

## Key findings

- Good knowledge and positive attitudes significantly increase the likelihood of good EENC practice.
- A favorable implementation climate, especially in rewards and leadership, is strongly linked to better EENC attitudes and practices.
- Heavier workloads reduce positive attitudes toward EENC, which in turn affects practice quality.

## Abstract

The World Health Organization (WHO) recommends Early Essential Newborn Care (EENC) to improve newborn outcomes. However, uptake remains suboptimal in many low-resource settings. Organisational factors, such as implementation climate, are crucial but understudied in relation to EENC implementation.

To explore how implementation climate mediates the relationship between knowledge, attitudes, and EENC practices.

Multi-site, cross-sectional study.

Twelve tertiary maternity hospitals in China (December 2022–April 2023).

433 nurse-midwives.

Validated questionnaires were use to assess knowledge, attitudes, practices, and perceived implementation climate related to EENC. Path analysis and logistic regression were employed to explore direct and indirect relationships.

A total of 69.3% participants reported good EENC practice. Significant predictors included good knowledge (adjusted odds ratio [AOR] = 2.75; 95% confidence interval [CI]: 1.76–4.31), positive attitudes (AOR = 2.00; 95% CI: 1.17–3.41), in-service training (AOR = 1.88; 95% CI: 1.17–3.02), holding a middle leadership role (AOR = 2.24; 95% CI: 1.20–4.17), and perceived workload. Nurse-midwives who reported heavier workloads were 48% less likely to hold positive attitudes towards EENC (AOR = 0.52; 95% CI: 0.28–0.94), which subsequently affected their EENC practice. The mean score of implementation climate was moderately favorable (3.30 ± 0.77), with the lowest in the rewards domain (3.02 ± 1.11). A one-point increase in climate score was associated with significantly higher odds of a positive attitude (AOR = 4.56; 95% CI: 2.98–6.99). Implementation climate influenced EENC practice indirectly through attitudes (RMSEA = 0.039).

This study highlights the importance of both individual factors and organizational climate in shaping EENC practices. To improve EENC implementation, healthcare systems should prioritize enhancing the implementation climate through leadership support, establishing appropriate reward systems, and addressing workload challenges. Additionally, integrating EENC training into continuous professional development programs and strengthening support for mid-level leadership are key strategies.