Expertise as an object-oriented and contradiction-driven activity.

The activity of the parties is analysed as activity systems consisting of both object-oriented individual actions and the broader communal and societal boundary conditions of the actions. For example, the person giving birth is an active subject in their activity system, using material tools and symbols, so-called mediating tools, which are characteristic of childbirth and have developed in the culture. Childbirth activity is directed at and motivated by the object, a positive overall childbirth experience, in which case the empowerment of the person giving birth emerges as the outcome. Both formal and unspoken rules regulate childbirth activity, as well as tacit norms that apply to births. Community is a central element comprised of people who share the object, in this case, assist or are otherwise socially involved in the birth. Division of labour defines the tasks and responsibilities of activity, assigning special roles for the subject of childbirth and the participating professionals and laypersons [cf. 16,11].

For its part, the community of the person giving birth determines who can be subjects in the childbirth activity, and it often consists of a childbirth support person important to the person giving birth. An OHD, where a health care professional cannot be present, changes the structure of the activity system, the division of labour and the role of the support person from a community background support to the subject, the LP [9]. In these unexpected and risky childbirth events, the LP may become confused about their role and worry about the wellbeing of the person giving birth and of the baby, and hide their negative feelings to protect the person giving birth [13,18–20]. This study focuses on the LP’s activity and cooperation with the ED [see 21], i.e., the relationship between the activity systems of the two subjects in an unplanned childbirth event.

Typically, after calling the midwife of the delivery room, the LP in need of help almost without exception calls the emergency telephone number as they become aware that they will not make it to the maternity hospital in time [11,13,22]. Theoretically, the emergency call is a mediating tool in the communication between the ED and the LP. In Finland, the progress of the discussion between ED and LP during the emergency call is guided by an established plan, i.e., the national risk assessment instructions on processing health care tasks at the Emergency Response Centre [see 23]. This mediating artifact regulating the course of interaction is a progression chart, which in activity theoretical research has been referred to as the formal script of cooperation. Disturbances and innovations observed in the practical work can be interpreted as deviations from the script and as expressions of developmental contradictions in activity systems [24]. Fig 1 summarises the theoretical background examined above, the construction of expertise as object-oriented activity in the disruption-prone interactional relationships between activity systems [9].

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Fig 1. Construction of emergency dispatcher’s expertise in the interaction between object-oriented and contradiction-driven activity systems.

https://doi.org/10.1371/journal.pone.0327808.g001

Applying negotiated knotworking.

In health care service systems, permanent teams are replaced with flexible expert configurations as non-linear cooperation between employees or organisations occurs in temporary and dynamic networks, knots, formed around a specific challenging task [25]. Engeström [26] has suggested ‘negotiated knotworking’ as “an emerging mode of activity describing the fluent and constantly changing settings of collaboration in client-oriented work.” Unlike traditional networking, negotiated knotworking is an improvised form of collaboration where the activity is not based on strict rules or hierarchies. Negotiated knotworking manifests as the subjects’ mutual design or problem-solving effort in activity systems oriented towards a shared object. Border crossings between different professions and competence areas and destabilisation of established power structures can be observed in the work [26].

According to Engeström [9], negotiated knotworking, like collective activity systems, is the ‘spearhead’ of research when the research interest is the development of collaborative and transformative expertise. Engeström and Pyörälä [27] argue that negotiated knotworking is one of the core elements in the development of medical expertise. We suggest that negotiated knotworking is an important consideration in the analysis of OHDs, in which unexpected and risky events pose challenges to expertise and require an instant response and negotiation of temporary practices [25,26]. In this study, the context of the setting depicted is the collaboration of the ED and the LP and negotiated knotworking to achieve a positive overall childbirth experience that includes childbirth safety. Negotiated knotworking has been analysed in multiple health and social care work studies. Recent examples include studies on opportunities for computer-aided knotworking for health care agents [28], and on forms of multi-professional cooperation and learning in health care [29].

Engeström et al. [25] discerned three dimensions of knotworking: i) socio-spatial, ii) temporal, and iii) ethical. Each of these dimensions is discursively elaborated on in the participants’ talk. Thus, the socio-spatial dimension is manifested in the questions of who is and who should be involved in the collaborative activity at hand. The temporal dimension is addressed in the informants’ accounts of the pulsating activity, in which knots are tied and untied in various rhythms of time. In health care activities, the ethical dimension is a central theme reflected in questions of how to meet vulnerability, how responsibility and power are renegotiated among the participants in acute situations. In addition, collaborating parties may assess the tools and practises that mediate the knotworking actions in iv) the material–instrumental dimension. Designing and implementing tools may stabilise and institutionalise instant knotworking practices [25].

Sampling and recruitment.

The material used in this study is the stories (n = 31) collected from Finnish EDs employed by the Emergency Response Centre Administration in Spring 2024 using the method of empathy-based stories (MEBS) [30]. The EDs were recruited between January 30 and April 1, 2024. This data was complemented by semi-structured interviews (n = 5) of LPs who had handled an OHD under the guidance of an ED between 2019 and 2024 [31]. The LPs were recruited between December 1, 2023, and March 29, 2024.

The Emergency Response Centre Administration granted the research permit regarding MEBS in December 8, 2023. The invitation to participate in the study was sent to all EDs in Finland (N > 400). The contact person named by the Emergency Response Centre Administration forwarded the invitation and the link to the electronic questionnaire to EDS. The invitation was extended four times.

To obtain the semi-structured interview material, the few LPs in Finland who have performed an OHD under the guidance of an ED were approached through the people who had given birth and were interviewed in a previous study on childbirth experiences [11]. An interview invitation was also published on the Finnish Midwifery Society’s social media, and press releases were published in the Finnish media. Each recruitment strategy required the consent of the person giving birth for the layperson to participate in the study. Communication took place by telephone, letter and email.

Data collection.

The empathy-based stories (MEBS) method sought the perspectives of EDs, and the semi-structured interview material sought the perspectives of LPs. The first author was sensitive to the ability of both informant groups to participate in the study and give their answers, leading to two different but still comparable data types. The first author designed the research, collected the data, and prepared the data transcriptions for the analysis.

The MEBS data was collected by the first author between 6th February and 6th April 2024. In addition to writing the story, background information was also collected from EDs in order to describe the material: level of education, occupational group, age, gender, work experience as an emergency dispatcher and the number of deliveries performed by instructed laypersons. The EDs empathised with the fictitious situation indicated in the frame story, i.e., the script (data in S1 Appendix), and based on that, wrote a story on the Webropol platform. The variable factor was the successful (well-script, WSED) or unsuccessful (unwell-script, UWSED) completion of the OHD from the perspective of a professional. The response time was not limited in advance, but a deadline of two months was set for the response. The investigator could not verify where the stories were written or whether other persons were present. The survey and reporting tool randomly selected which version of the frame story each informant received. The scope of the stories written based on the first frame story (WSED) (n = 15) was 2202 words, and the average length was 147 words. The scope of stories written based on the second framework report (UWSED) (n = 16) was 1859 words, and the average length was 116 words.

To collect the semi-structured interview material, Zoom interviews were conducted between 14th December 2023 and 14th March 2024. The themes were based on a theoretical preliminary understanding but left room for differing interpretations and views [32]. The interview themes (data in S2 Appendix) were derived from a literature review [e.g., 13,18–20], the researcher’s expertise and the concepts of CHAT [33]. The first author was the interviewer. The framework of the semi-structured interview was tested on a voluntary LP belonging to the target group. When the pilot interview proved successful, it was included as part of the material of this study. No material or interview themes were sent to the interviewees in advance. The subjects participated in the Zoom interview from their homes and no outsiders were present during the interviews. The LP interviews were recorded. The total length was 5 hours and 40 minutes (min 69 and max 94 minutes per interview, 85 minutes on average). The material was transcribed (total of 48,837 words, an average of 12,210 words in Finnish). The transcripts were not submitted to informants for comment. However, two subjects wanted to supplement their interview by email, and the supplements were included in the material of this study.

Subject: emergency dispatcher.

Object: In the EDs’ stories (WSED and UWSED combined, n = 31), the most frequent words were “mother” and “child”, describing the importance of the physical wellbeing of the two typical objects of activity in a childbirth task. In unexpected, risky and rapidly progressing unplanned childbirth events, decisions had to be made quickly as there was often not enough time for negotiation and construction of a shared object. The experiential nature of the activity was taken into account in some stories:

The mother may find it difficult to concentrate on giving birth, and the childbirth experience may become poor; for example, tolerating pain is more difficult when the situation is unsafe and unplanned (Participant 18, UWSED).

Tools: In their stories, the EDs gave the LPs relevant instructions by telephone to enable the delivery activity. In particular, the WSED stories (n = 15) highlighted the instructions’ clarity, adequacy and repetition.

At the same time, in the EDs’ stories, the relevant instructions describing both the tools and the object of the activity were primarily related to the newborn’s wellbeing, such as stimulation by drying, taking care of thermoregulation or starting basic resuscitation. The instructions related to the place and position of childbirth varied as long as the person giving birth was moved away from the toilet seat. Relevant instructions related to handling the delivery included, for example, uncovering the lower body and observing the presenting part in the birth canal, instructing the person giving birth to push during a contraction, and if the mother experiences severe bleeding, she is placed into the recovery position.

In particular, the UWSED stories (n = 16) expressed concerns about a situation in which both the mother and the baby were unwell, and the ED had to guide the LP in treating two critical patients requiring immediate action, forced to prioritise:

An unconscious, bleeding mother should be placed on her side, and resuscitation should be started for the baby. One layperson cannot take care of both. The layperson is trying to do their best, as am I. I’m trying to give instructions and keep everyone alive. The low number of maternity hospitals has driven us to this point, where an emergency dispatcher will face situations like this. (Participant 30, UWSED).

Rules: In the EDs’ stories, the delivery activity was guided by national risk assessment instructions on handling health care tasks at the Emergency Response Centre, the formal script of cooperation. Deviating from it caused noticeable disturbances in the childbirth task.

Especially in UWSED stories, disturbances had typically been caused by the reluctancy of the LP to view the external female genital organs, in which case the LP had questioned the ED’s instruction to examine the progress of labour visually:

Cultural differences affect, for example, whether a father or other male family member or loved one can even view what is happening in the private parts. This leads to hazardous situations if it is not actually known whether something abnormal is present. (Participant 22, UWSED).

In the stories, the LP had sometimes feared that they would worsen the situation and, contrary to the ED’s instructions, had not dared, for example, to loosen the umbilical cord around the baby’s neck in fear of tearing it. This had led to a stillborn baby. These deviations from the script by the LP being instructed caused confusion in the EDs in the absence of risk assessment instructions or visual contact:

I can only give a certain amount of support and instructions orally. Not everything can be handled remotely. (Participant 5, WSED).

Disturbances have sometimes been caused by the lack of a tool, common language, between ED and LP, making it impossible to ask questions, give instructions, or understand them.

In UWSED stories, disturbances had been caused by a Finnish-born person giving birth who had been thoroughly prepared for a hospital birth. The disappointment about the unplanned childbirth event had been expressed as acting up towards the ED and concretely as a refusal to follow the rules, instructions given by the ED through the LP.

Many UWSED stories showed that directing the LP in a car on the way to the hospital particularly challenged the script’s rules. Traffic noise interfered with communication, and often, the LP was driving, which diverted attention from receiving and following instructions and assisting the person giving birth. After the ED had instructed the LP to stop, difficult conditions in the front seat caused more disturbances as space was limited, and the seat was difficult to move.

Subject: layperson.

Object: The object of activity of all LPs interviewed was the joint effort of the LP and the person giving birth to complete the labour safely in order to achieve a positive overall outcome. Only one LP experience became partially negative and was described as a survival story containing self-accusation. The other LPs achieved a positive overall childbirth experience as the person giving birth and the newborn were well:

It was a natural, beautiful, good, and even sacred experience. Unique, unprecedented and incredible, so absolutely nothing negative. Pure plus. (Participant 2, LP).

The LPs identified the physical wellbeing of the mother and the child as the primary object of the EDs’ activity. They shared the experience of a narrow time window for negotiating a shared object.

Division of labour: Achieving a positive overall childbirth experience required the acceptance of the LP in the “childbirth bubble” of the person giving birth, either partially or completely. From the perspective of the division of labour in the activity system, this can be interpreted as a shared responsibility between the LP and the person giving birth while the ED provides meaningful instructions in the background:

The emergency dispatcher didn’t bring themselves to the focus but listened and followed the situation as necessary, giving support and instructions, but was not there inside our bubble. I didn’t think there were three of us in this childbirth, but that there were just the two of us living this thing (Participant 1, LP).

Outcome: The shared intimate experience – which the LP had rarely talked about afterwards with people other than their loved ones – often resulted in the strengthening of the relationship between the LP and the person giving birth:

We have been on the same side of the table and looked in the same direction, experienced a shared positive trauma, a successful unplanned delivery outside of a hospital. Nothing could unite two people and a relationship more. (Participant 3, LP).

Sometimes, the experience resulted in a special bond between the LP and the child born unplanned outside of a hospital.

Tools: Some of the LPs viewed themselves as subjects in their activity system. To handle the OHD, they needed relevant instructions from the ED and ad hoc information for delivery. The LPs appreciated detailed, concrete, and easy-to-understand instructions. Some felt that instruction from different EDs was not consistent.

The instruction related to the wellbeing of the newborn, to take care of the thermoregulation, was highlighted as relevant in many LPs’ interviews. The instruction to move the person giving birth away from the toilet seat was viewed as relevant in many LPs’ interviews. However, the instructions related to delivery, not to pull the baby, were often found confusing. In many LPs’ interviews, the instructions to remove the foetal membranes from around the baby’s head and on the assessment of the amount of lochia were highlighted as relevant.

The interviewed LPs also brought up certain situations related to handling unplanned childbirth events where they felt they had not received related instructions from the ED. Especially the lack of instructions related to considering the intimacy of the person giving birth was found to be one. The needs of the LPs for relevant instructions left unreceived from the EDs were related to considering the colour of the amniotic fluid, loosening the umbilical cord around the baby’s neck, the afterbirth, the closing of the umbilical cord and preparing for excreta:

Because it looks so messy when the water breaks, and of course, there’s some blood there as well (Participant 2, LP).

Rules: The childbirth activity of the LPs was guided by the risk assessment protocol, where deviations sometimes produced disturbances. The LPs identified the disturbance in following the instruction, which was caused by the lack of a common language. The LPs felt that the disturbances could be related to the person giving birth coming from a different culture, and better knowledge of the structure of circumcised female genitalia was needed from the ED.

Disturbances related to childbirth in a car emerged in one LP’s interview. They were linked to excessive speed when driving to the hospital, lack of space or the unsafety of driving immediately after the childbirth event:

My speed was 220 kph, I had a phone on my ear, one hand on the wheel and the other hand in a way that the person giving birth could sink her nails in it (Participant 3, LP).

In two LPs’ interviews, the disturbance had been caused by the ED, who had interpreted the voluntary labour support person (doula) to be a professional in handling childbirth rather than an LP. This misinterpretation resulted in the cooperation situation being broken just before the moment of birth.

Script innovations requiring midwifery competence.

In the EDs’ stories (WSED and UWSED combined, n = 31), the challenge level of an unplanned childbirth situation was increased by the difficulty of forming a situational picture over the phone:

Different words and views pose challenges during calls whenever the dispatcher works with the layperson acting as their eyes. I try to handle these changing situations using different wordings and sentences so that the dispatcher can “see” the situation as it really is. (Participant 29, UWSED).

Several development needs for a new kind of tool, video consultation, facilitating the formation of a situational picture, could be identified from the MEBS data. In the EDs’ stories, the video connection was seen to extend the possibilities of instructing LPs and achieving a positive outcome in future OHDs. These situations identified to support the use of the ED’s sense of sight during labour included, for example, the visual examination of the presenting part to assess the progress of labour, the examination of the childbirth position, guidance of releasing the umbilical cord from around the neck, and the assessment of the condition of the newborn or the amount of lochia. In EDs’ stories, a video connection would help prevent disturbances, especially in the absence of a common language or when the LP’s attitude challenges the script. Using the sense of sight was considered necessary when the sounds of childbirth or traffic noise hindered verbal communication. The LP interview data could also identify innovation attempts to develop video consultations.

In the EDs’ stories, instructing the LP in the OHD was considered particularly demanding because the training received for the task of childbirth had been brief, their expertise undeveloped, and the routine missing. However, most of the LPs interviewed relied on the ED’s expertise in handling childbirth, even though they did not always know whether it existed. They felt that the ED had acted well in the childbirth situation and appreciated the ED’s expertise in perceiving the overall picture – especially on the way to the hospital – and in alerting additional help. On the other hand, the EDs hoped that midwives familiar with genuine 791 emergency call recordings (791 is the code for a childbirth task) would provide additional and supplemental training for future childbirth tasks. The respondents wanted help from experienced midwives to update the risk assessment instructions.

It is significant that in the LPs’ interviews, the midwife of the maternity hospital had, without exception, been called before the emergency call, sometimes several times, which describes the LPs’ wish to primarily deal with a midwife in a situation related to childbirth:

When we left home, I called the maternity hospital and said we would be coming in pretty fast. Then I called them again before calling the emergency response centre (Participant 3, LP).

However, according to the LP interviews, the telephone connection to the midwife had not been open in any of the cases at the moment of birth, either after the maternity hospital had placed the call on hold or because the midwife had directed the LP to call the emergency response centre after childbirth is noted to take place soon. Although the midwife of the maternity hospital had sometimes called the LP back after the childbirth, after the emergency call had ended, most LPs hoped that the ED would have involved the midwife in the call to support and instruct them in handling the OHD. Alternatively, they wished that the ED had been a midwife by training:

Nobody consulted the midwife at any point. The fact that you have been with women giving birth, you can immediately see what might happen. That there is someone who understands and knows it would be extremely important. (Participant 2, LP).

Innovation attempts to develop video consultations, including the presence of both a midwife and the ED, could also be identified from the LP interview data, where both would simultaneously instruct and support the handling of the OHD.

Emotion work.

Slightly more than half of the EDs and all LPs recognised that emotions were fundamentally related to the handling of rapidly progressing delivery tasks:

Childbirth is a time-restricted, sort of unstopping process in which big emotions are present (Participant 18, UWSED).

In both EDs’ stories and LPs’ interviews, it had almost always been the LP that called the general emergency number 112. When childbirth was noted to take place before a health care professional could reach the site, the ED had to take into account the strong emotional charge connected to the situation and calm the LP down. In their stories, the EDs typically interpreted the emotional state of the LP as tense, nervous, anxious or panicked, which corresponded to the experiences of most of the LPs interviewed. In particular, the fear of the LPs was increased by the fact that the person giving birth was someone close to them.

In the EDs’ stories, the LP had to be calmed down so that they could listen and answer questions in the risk assessment protocol or receive instructions. Measures aimed at calming down the LP were motivating, encouraging, inspiring, and strengthening faith in a successful end result, which were highlighted especially if the person giving birth’s condition deteriorated. Most LPs felt that the ED had succeeded in calming them down.

The words most frequently used in WSED stories were “informant” and “tells”, which reflects the importance of calming down the LP for the query protocol to succeed. In these stories, the LP calming down often led to maintaining cooperation and functional capacity, the significance of which the EDs recognised as a prerequisite for achieving a successful result. All interviewed LPs felt that their functional capacity had remained – sometimes it had even improved in the childbirth event involving strong emotional stress:

My functional capacity went to the extreme, like the best possible condition: I will rock this to the finish and will not freeze (Participant 3, LP).

The LP calming down was needed in order for the LP to reassure the person giving birth, who was often described by EDs in their stories as in their childbirth bubble, incapable of communicating or cooperating, distressed, panicked or screaming in terror. Many LPs felt that the person giving birth being reassured was achieved without using words, especially because the person was close to them. After the calming down, childbirth also often progressed rapidly.

In their stories, the EDs described being typically tense or even slightly panicked when receiving the childbirth task. However, this was not reflected in the interviews of most LPs, who rather appreciated the ED’s calmness. The EDs had received mental support from other emergency dispatchers in the room who had observed the call.

In both the EDs’ stories and the LPs’ interviews, after childbirth, the LPs’ emotional state typically changed to great relief. Despite this, almost all interviewed LPs felt that they needed debriefing.

The emotional state of the persons giving birth was described as having changed to relief or crying from happiness after the birth. However, the EDs’ own tension in the stories had typically only been released when the baby’s crying was heard:

At the same time, the situation is peaceful, but there is a small panic inside me, which, of course, I will not reveal to the layperson. Simultaneously, I’m going through the scenarios that could occur after the birth. What if the mother starts bleeding severely, or the child doesn’t start crying. (Participant 5, WSED).

In the WSED stories, the EDs’ own tension when the mother and the newborn were physically well had typically turned into a great joy, which was often shared with other personnel in the emergency response centre who had listened to the call. The ED often thanked the participants, remembered to congratulate the person giving birth and the LP, and enquired about the baby’s gender. However, even a successful childbirth event had often left both the ED and the LP thinking, both of whom felt small in the face of the miracle of birth. On the other hand, UWSED stories typically highlighted the ED’s feelings of inadequacy and powerlessness, even quiet terror.

The findings of RQ1 and RQ2 are summarised in Fig 2, displaying activity systems in interaction and preliminarily identifying the themes of knotworking that shape and challenge their collaboration.

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Fig 2. Emergency dispatcher’s expertise as negotiated knotworking.

https://doi.org/10.1371/journal.pone.0327808.g002