Introduction:

The International Confederation of Midwives (ICM), under the motto "The world needs midwives now more than ever!” warned all countries of the world, the need for midwives to develop their skills differently and independently, emphasizing for the indispensability of these professionals in health institutions, both in hospital and community context. A unique feature of this profession inevitably by highly differentiated care to women and their families, understanding the woman as a promoter of reproductive health of individuals and populations (International Confederation of Midwives, 2009)¹. The exercise of maternal health nursing and midwifery profession is self-regulated, with a body of knowledge and own a domain with highly specialized skills. Much of this knowledge that maintains specific practices of caring, stems from research undertaken by these professionals, which over time have data undoubted contributions in the evolution of care aimed at women, children and families. In this sense, according to Law No. 9/2009 of 4 March in Portugal the activity professional midwife is exercised by Specialized Nurses in Nursing and Obstetrics Maternal Health, having transposed into national law the requirements for training and areas of practice of midwifery. These professionals can pursue their practice in hospitals, health centers, clinics and home care environments².

According to the International Confederation of Midwives (2009) many countries, including Portugal, currently lack opportunities for specialized Nurses in Nursing and Obstetrics Maternal Health and expand their autonomous power to intervene in this matter towards developing empowering these professionals to exercise of its powers.

Lafrance & Mailhot (2005)³ report that the power of the midwife is based on a relationship that is based on a partnership between the midwife, the woman and her family, and empowering an intentional process of health professionals to share knowledge and power, which contributes to the ability and willingness of a woman to make choices that are in harmony with her and their values, while allowing the health professional to perform safely and autonomous actions that arise from their choices.

According to Freire (1992)⁴ the application of the concept of empowerment in the practice of midwifery emphasizes that this approach focuses on the skills of these professionals to develop their own practices with a view to active participation of the mother and developing their own capabilities. Also understand that the process of empowerment does not occur without the contributions of each partner.

Hermansson & Martensson (2010)⁵  researchers from the University of Gothenburg in Sweden, emphasize that empowerment is a difficult concept to understand, define and translate in different contexts. For these midwives empower women through their practices in the beliefs and values sustained significant for gender, using tools such as research and health education, also reflecting his own professional empowerment.

Taking into account the current context of nursing training in Portugal, especially the midwives, who hold a four-year pre-graduate training and two years of postgraduate training, there are no national studies that show us the same level of empowerment. For Matthews, & Scott Gallagher (2009) (6), in the current context of change, need for scientific evidence to allow us to identify the perception that midwives have their level of empowerment, enabling the measurement of the conditions that facilitate training and help to increase the contribution of these professionals in the care of women and families throughout the reproductive cycle. Thus, it seems important to know the levels of empowerment of Specialized Nurses in Nursing and Obstetrics Maternal Health in Portugal.

Method:

According to Fortin (2009, p.19)⁷"the research methodology presupposes both a rational process and a set of techniques or means to carry out the investigation."

Given the objectives of the study, and the absence in Portugal a validated instrument to determine the level of empowerment of midwives, it was necessary to proceed to the first cross-cultural validation of a measuring instrument, allowing for an instrument to investigate the assumptions inherent in the empowerment of Specialized Nurses Nursing Obstetric and Maternal Health.

Given that our research looking for an explanation of the relationships between variables, we have chosen in this way by resorting to quantitative methodology, which second Fortin (2009, p.27) "is characterized by measured variables and for obtaining numerical results in liable be generalized to other populations. "According to the same author, this type of methodology, whose distinctive features are objectivity, prediction, control and generalization is based on the observation of facts, events and phenomena and objectives established by a systematic process of data collection and observable measurable. It was our purpose to conduct a cross-sectional, non-experimental and descriptive.

Understanding that a goal is a declarative statement that needs the guidance of research taking into account the level of knowledge that were established in the area in question, the goal of a study should harmonize with the degree of advancement of knowledge and also specify the variables , the target population and the context under study (Fortin, 2009). In order to orient our research, we set the following goal: To know the level of empowerment of Specialized Nurses Nursing Obstetric and Maternal Health in Portugal.

The stated research question for this study is: What are the levels of empowerment of Specialized Nurses Nursing Obstetric and Maternal Health in Portugal?

The population "consists of a set of individuals or objects that have similar characteristics, which were defined by inclusion criteria, with a view to a particular study" (Fortin, 2009, p.55). It is understood by a split sample of the target population which focuses on the investigative process.

Because this study involves a cross-cultural validation of a measuring instrument consists of 22 statements, it is "essential that the sample is sufficiently large to ensure that a second analysis remain the same factors" (Almeida & Freire, 2008, p. 120)⁸.

Considering that the minimum valid responses (N) is given by N = 5 x K (where K> 15), where K is the number of issues of the instrument, which we define for the accounting of minimum sample size would be required for least 110 Specialized Nurses Nursing Obstetric and Maternal Health (Pestana & Gageiro, 2005)⁹.

According to Almeida & Freire (2008, p.120) "the representativeness of a sample is essential and the most important condition in an investigation, especially when trying to generalize the results obtained from a sample to the population." To make this possible, it is necessary that the population is "reflected" in the sample considered, "where the authors consider a sample of 300 subjects for significant validation of instruments with a large number of items.

Thus, in this work we target population Specialists Nurses Nursing Obstetric Maternal Health and Portuguese, registered and recognized by the Order of Nurses, to develop care within their area of expertise of mothers in the hospital setting and who agree to participate in the study. As a sampling, not resorted to sampling probabilistic networks. Given these assumptions, participated in research 309 Specialized Nurses Nursing Obstetric Maternal Health and Portuguese.

To carry out this research work proceeded to the completion of a questionnaire organized into two distinct parts. The first part has allowed us to collect sociodemographic data and professional respondents. In the second part we used the scale 'Perceptions of Empowerment in Midwifery Scale' (Matthews, Scott & Gallagher, 2009), in which there was need for the transcultural validation of this measurement tool.

Results:

a. Data relating to the validation of the Transcultural Scale of Perceived Empowerment of Nurses Nursing Specialists Obstetrical and Maternal Health (PEMS):
Anne Matthews, Anne Scott & Pamela Gallagher, researchers at the University of Dublin, Ireland, conceived in 2006, an instrument that represents a first attempt to develop a scale that is based on perceptions that midwives believe is important for their empowerment and empowerment, having been published in 2009. The need to study the level of empowerment of Specialized Nurses Nursing Obstetric and Maternal Health in Portugal, and the diminutive research in this field, we believe it is fundamental to its application in this research by implying that the whole process of conceptual and psychometric validation of this instrument.

The linguistic and conceptual equivalence of an instrument should enable the semantic equivalence of the concepts between the two cultures. According to Fortin (2009) for a measuring instrument is equivalent to the original, or the cultural level or the functional level, it is essential that the investigator is familiar with the patterns linguistic and cultural differences between the home country and the country in which is to adapt the instrument.

Translation from English to Portuguese from 'The Perceptions of Empowerment in Midwifery Scale (PEMS)' was performed independently by two bilingual Portuguese. The researcher also conducted the independent translation of the instrument. During the translation were made some contacts with translators to clarify issues related to the translation of equivalence. If the translation has the same meaning as the original version (equivalence of the item). It was explained the purpose of the measuring instrument and the intentions underlying the conception of each item.

The analysis of the differences between the three versions of the translations were performed by the researcher, thus resulting to the first draft of PEMS in Portuguese (version 0.1). Next to this stage, has begun the process of retroversion, the same was done by two bilingual translators, without prior knowledge of the original scale, both professional translators, resulting in the second draft of the PEMS (version 0.2). Comparing the two versions were not found conceptual differences, made up by investigating the adjustment of the instrument resulting the third draft of the PEMS (version 0.3).

To ensure the conceptual equivalence of measurement instrument proceeded to validate inter-judges. Thus, the third draft of the PEMS (version 0.3) was submitted to a panel of judges, six experts in the culture of the target population and the constructs of the scale, having been set the criterion that they should be experts in the field of research and maternal health nursing and midwifery.

After examining the reply from experts and new adjustment of the measuring instrument, resulted the fourth draft of the PEMS (version 0.4).

The following steps consisted of Reflection Spoken (Thinking Aloud) on the measuring instrument and the application of pre-test of the fourth draft of the PEMS (version 0.4) to a group with similar characteristics to the study population - 4 Nurses Health Nursing Specialists maternal and Obstetric, exercising care of mothers in the hospital setting in Leiria hospital (Portugal). This procedure aims to test: shape and visual appearance; understanding of instructions; understanding of different items; receptivity and adherence to the content, proceeding in this way the operational equivalence. This process led to the fifth draft of the PEMS (version 0.5).

After analyzing and recording of changes resulting from the application of pre-test and reflection spoken version obtained was sent to the authors of the original scale to validate the significance of each item (semantic equivalence). From your agreement emerged the final version of the instrument, the Scale of Perceived Empowerment of Nurses Nursing Specialists Obstetrical and Maternal Health (PEMS-PT; version 0.3).

To evaluate the psychometric properties of any measuring instrument, in this case the PEMS in Portuguese, it is necessary to perform reliability and validity studies that, taken together, indicate the degree of generalization that can achieve results (Fortin, 2009).

Fidelity refers to the accuracy and constancy of measurements obtained with the help of a measuring instrument for Fortin (2009, p.348), "refers to the ability of the instrument to measure at one time to another one covered by a steadily (notion of reproducibility of measurements)”. The measuring instrument is faithful if measures in the same way in similar situations.

The degree of fidelity is expressed in the form of a correlation coefficient (r) on a scale ranging from 0.00 (no correlation) to 1.00 (perfect correlation). Thus, if the coefficient approaches 1.00, the instrument generates fewer errors and is considered "highly accurate", and the opposite true for the close correlation of 0.00 (Fortin, 2009).

Given the scale of the original version, first tried to determine the internal consistency of each subscale, looking to go back to what was done by the authors. We observed that face each subscale have loyalty standardized coefficients (standardized alpha) ranging from the value of 0.368 for the sub-scale 'Women Centred Practice / Practice Centered Woman', the value of 0.524 for the sub-scale 'Autonomous Practice / Independent Practice 'and 0.850 for the sub-scale' Effective Management / Effective Management ' (table 1).

Table 1: Loyalty coefficients standardized from three dimensions of PEMS.
Font: Matthews, A.; Scott, A.; Gallagher, P.; Corbally, M. - An exploratory study of the conditions important in facilitating the empowerment of midwives. Midwifery 22, (2006), p.330.T

Thus, compared to the values obtained for each sub-scale and two of which are below what is considered acceptable for loyalty standardized coefficients (Hill & Hill, 2005)¹⁰, we believe that would be an option methodological determine the coefficients of fidelity standardized for any scale, including 22 items. We obtained an alpha standardized 0.811, while items 3, 4, 7, 17, show a correlation with the total range of less than 0.200.

Taking into account the assumption that items should have a correlation with the total scale greater than 0.200 (Almeida & Freire, 2008), we determined new coefficients standardized loyalty, now without the items mentioned above, a total of 18 items. We note that we obtained in this new calculation a standardized alpha of 0.829, significantly better than the previous, and item 18 shows a correlation with the total scale of less than 0.200.

Based on the same criteria item 18 was eliminated, obtaining a coefficient of fidelity standardized 0.832, a value considered very good (Almeida & Freire, 2001) compared to 17 scale items, all of which have a correlation with the same total exceeding 0.200 (Table 2).

Tabela 2: Coefficients of standardized fidelity of 17 items forming the PEMS.

Fortin (2009, p.354) states that the validity "refers to the degree of accuracy with which the concept is represented by a particular set of measurement instrument", is the guarantee that the test can measure what it intends to measure. Construct validity (conceptual validity) is par excellence, the pursuit of scientific usefulness of the instrument, because it connects directly attribute that to the theory proposed measure through that test.

It is the ability of the instrument to measure the concept or construct theoretically defined and it is to examine relationships underlying theoretical construct an instrument (Fortin, 2009). The construct validity of PEMS-PT was verified by factor analysis. This consists of identifying the functional units (factors) constituting the test and the contribution of each to the overall results or to determine whether to set a scale regroup around one or more factors (Fortin, 2009), which allows confirmation of the theoretical constructs put on. For Almeida & Freire (2008, p.199) "the factor loading of an item on the factor, reflects the extent to which this item is behaviorally a given latent trait (validity), ie the percentage of covariance between this item and the appropriate factor.”

With the results, and having been met methodological criteria explained above, the 17 scale items were included in the factor analysis, determining the Kaiser-Meyer-Olkin (KMO) test and Bartlett's sphericity, measuring the level adequacy of the data for factor analysis.

It was observed that the Kaiser-Meyer-Olkin index indicated a 0719, and the test of sphericity was widely Bartlett `s significant (p ≤ 0.000). Thus, these figures indicate that the principal component analysis can be done, since the measure value of Kaiser-Meyer-Olkin (KMO) is acceptable, and these results indicate the adequacy of the data to perform the factor analysis.

The construct validity was performed as in the original, through principal components factor analysis with orthogonal rotation method of Varimax. For the analysis performed, we have obtained best results with a matrix of five factors, wherein the same explains about 72.90% of the phenomenon under study (table 3).

Tabela 3: Coefficients of factor analysis with orthogonal rotation by varimax rotation method.

After the results, the Portuguese version of the instrument was renumbered 1-17, with the five factors were named given the original version of the scale and the factors that constituted, but also the appropriation of theoretical constructs that characterize the practice Nurses Nursing Specialists Obstetrical and Maternal Health in Portugal, as based on the different constituent items (table 4).

The first factor was labeled 'Effective Management and Interdisciplinary Relations' and includes nine items (1, 3, 4, 5, 7, 10, 15, 16, 17) that relate to the support and effective communication with professionals connected directly to management activities (head nurses, managers, administration), the perception that nurses are experts or not they are informed about changes affecting their practices, such as autonomy in the exercise of their profession and the ability to say no when they judge that it is necessary, both in terms of the management, both in its relationship with other professionals, including physicians.

 The second factor was labeled 'Sustained and Autonomous Practice' and includes four items (2, 8, 11, 12) for the control, theoretical framework and practice on the exercise of clinical nurse specialists and defend the real interests of the pregnant women.

 The third factor, entitled 'Professional Communication and Consent' includes two items (6, 9) which relate to communicating effectively with management bodies and the relationship between colleagues Specialized Nurses in Maternal Health Nursing and Midwifery, such as their support.

 The fourth factor, entitled 'Recognition Team Health' refers to a single item (13) on recognition of professional nurse specialist in maternal health nursing and midwifery by the medical profession.
 The fifth factor, titled the 'Education and Training' with a single item (14), relates to aspects of the education and training of peers in the profession of Nursing Nurse Specialist in Obstetrics and Maternal Health.

In short, the English version of the Scale of Perceived Empowerment of Nurses Specialist Obstetrical and Maternal Health - PEMS-PT, is a Likert type scale of five points (1 - Strongly Agree, 2 - Agree 3 - Disagree / Disagree Neither ; 4 - Disagree, 5 - Strongly Disagree), consisting of 17 items, wherein the minimum value (Xmin.) is 17 and the maximum value (Xmáx.) is 85. The higher the value obtained on the scale (approaching the maximum), the lower the level of empowerment percecionado by Specialized Nurses Nursing Obstetric and Maternal Health and the lower the value obtained on the scale (approaching the value minimum), the greater the level of empowerment percecionado by Specialized Nurses Nursing Obstetric and Maternal Health. We consider the average value (Xmed.) of the scale, the value resulting from the sum of the maximum value (Xmáx.) with the minimum value (Xmin.), dividing this value by two and added to the minimum value (Xmed. = ((Xmáx. - Xmin.) / 2) + Xmin.). Identical to the mean values obtained are considered medium level of empowerment, above this value is considered low level of empowerment and below this, a high level of empowerment.

Through factorial matrix were created five dimensions of the scale include: Effective Management and Interdisciplinary Relations with 9 items (Xmin = 9; Xmax = 45); Practice and Sustained Autonomous with 4 items (Xmin = 4; Xmax = 20), Communication and consent Professional with 2 items (Xmin = 2; Xmax = 10); Recognition Health Team with 1 item (Xmin = 1; Xmax = 5); Training and Education with 1 item (Xmin = 1; Xmax = 5).

As we can see there are two dimensions, consisting solely of a single item, however we understand keeping them given the importance of conceptual content and the fact that this research involves cross-cultural validation of the measuring instrument, and its use is to be held for the first time.

Tabela 4: Array of scale factors 5 Realisation of Empowerment of Nurses specialize in Obstetric and maternal health Nursing-PEMS-EN

b. Characterization of the sample regarding sociodemographic data and professional and of the level of empowerment

For the data analysis, we found that the average age of Specialized Nurses Nursing Obstetric and Maternal Health who participated in our study is 39.96 years (σ = 8.35), with a minimum value (Xmin.) of 25 and a maximum value (Xmax.) 57 years of age.

With regard to marital status shows that 65.40% (202) of Specialized Nurses Nursing Obstetric and Maternal Health are under the de facto / married, with 16.20% (50) were single and 15 50% (48) are divorced / separated.

Regarding academic, 44.70% (138) of the participants in our study pós-graduation hold the course in nursing. It was also observed that 41.70% (129) of them have a degree of equivalence licensed by the specialty of obstetrics and maternal health, and 13.60% (42) have a master's degree.

Given the type of employment contract / relationship with the institution, 86.40% (267) of nurses holding a contract of indefinite duration (CTTI), 6.50% (20) a contract of employment for a fixed term (CTTC) and 7.10% (22) of
You can see that, on average, nurses have 8.10 years of professional experience as Nurse Specialist Obstetrical and Maternal Health, with a standard deviation of 5.81 with minimum of 1 year and a maximum of 22 years.

Regarding the level of empowerment percecionado by Specialized Nurses Nursing Obstetric and Maternal Health (Table 5) by using the Scale of Perceived Empowerment of Nurses Nursing Specialists Obstetrical and Maternal Health (English version) - PT-PEMS, observed that the average level of empowerment of nurses who participated in this study is 64.39, with a standard deviation of 9.88. Whereas the higher the value obtained, the lower the level of empowerment, and given that the maximum range is 85 and taking as reference the average value (Xmed. = 51.00), we can consider that the overall level of empowerment nurses is low.

It was also observed that as regards the dimensions of five scale levels are low empowerment, and some, such as dimension 'Sustained and Autonomous Practice ", very close to the maximum values (Md = 19.00 , Xmax = 20.00).

Regarding the dimension 'Effective Management and Interdisciplinary Relations' found that the median value is 33.00, where the maximum value of the sub-scale of 45.00, so we can conclude that the level of empowerment to this dimension by percecionados nurse specialists is also low, which also happens to the dimensions 'Professional Communication and Consent' (Md = 8.00, xmax = 10.00), and 'Education and Training' (Md = 4.00, xmax = 5, 00).

It is still possible to observe that the dimension 'Health Team Recognition' that nurses hold a higher level of empowerment, since the median value is 3.00 (σ = 1.12), and the maximum value is 5,00.

Tabela 5: Characterization of the sample in relation to the level of empowerment.

Discussion of Results and Conclusion:

We began this discussion by characterization of our sample, finding that, when it comes to the age of Specialized Nurses Nursing Obstetric Maternal Health and it is an average of 39.96 years, with a majority (65.40%) are married / unmarried. These data are consistent with those studies within this thematic line developed by Matthews, et al. (2009), wherein the majority of Irish midwife who participated in the research carried out by these authors had an average age of 40 and 60% were also matched. In their study, Guililland (1999)¹¹, shows that the largest share of the nurses midwives have 40 or more years of age and hold the marital status of married / de facto union, also developed in research by Kirkman (2005)¹², with nurses Australian midwives, meets the results we obtained. In Portugal the study by Fernandes (2004) the 12 nurses who participated in the study were distributed between 35 and 60 years, predominantly younger than age 40 (67%).

Regarding academic training, we found that 44.70% of the participants in our study holds a postgraduate degree in nursing, with 41.70% of them have the degree of equivalence licensed by the specialty health nursing mother and obstetric and 13.60% had master's degree. These data are consistent with those obtained by Fernandes (2004)¹³ in which all professionals who participated in her research had the Course of Specialized Higher Studies in Nursing and Obstetric Maternal Health. When comparing the results of our work with international studies (Guililland, 1999; Kirkman, 2005; Matthews, et al., 2009; Reiger et al., 2009) found that the level of training of Nurses Nursing Specialists Health maternal Obstetric and Portuguese is the most advanced at the European or global, as we know, currently in Portugal, the Nurse Specialist Nursing and Obstetric maternal Health is one who has developed a training course at undergraduate and then a post graduation of two academic years, after two years of professional experience and is recognized as the nurse with an extensive knowledge in a specific area of nursing, taking into account the human responses to life processes, demonstrates high levels of judgment and clinical decision making, translated into an aggregate of expertise.

It was verified in our research that 89.30% of Specialized Nurses Nursing Obstetric Maternal Health and performing duties in essentially public institutions of capital and 10.70% of those performing duties in essentially private institutions of capital. According to data published by the Order of Nurses (2011)¹⁴ in 2010 there were in Portugal from 10,673 nurses between specialists in different areas, 2329 Specialized Nurses Nursing Obstetric and Maternal Health, with the majority working in public hospitals.

Currently midwives worldwide seek re-assert themselves and exercise their power with local communities and thirst for house calls. In their study, Cheyney (2008)¹⁵ titled 'Homebirth the systems-challenging praxis: knowledge, power, and intimacy in the birthplace' that examines the practice of midwives in the home context is understood as a return to supremacy of the power of these professionals in United States, associated with sovereignty given parturients and the cultivation of intimacy underlying the birth home.

It is analyzed on our research, that on average, nurses have 8.10 years of professional practice as nurse specialists. In the study by Fernandes (2004) in respect of years in the profession, there was a variation between 11 - 34 years, with the majority of nurses between 11 and 20 years in the profession (83%). The exercise time professional service varies between 3 and 22 years, predominantly in the range of 3-10 years. In research undertaken by Matthews, et al. (2009) Irish midwives were located, most (45.3%), between 0-10 years of professional experience, of which 28.8% was between the 11-20 years of professional experience.

Regarding the level of empowerment percecionado by Specialized Nurses Nursing Obstetric and Maternal Health, found that the average level of empowerment of nurses who participated in this study is 64.39 and can be considered that the overall level of empowerment of nurses is low.

Given that this investigation proceed to the first validation of the scale in Perceptions of Midwifery Empowerment Scale (PEMS), whose origins are Irish and as they say the authors, is the same as the first global instrument that is specific to obstetrics and is based on the perception that midwives have about their empowerment (Matthews et al., 2009, p.334), it is difficult to compare the results we obtained, since the scale validated by us has some changes compared the original either on the number of items (PEMS English version - 17 items) and on the number of factors / dimensions (PEMS English version - 5 factors).

With regard to the five factors / dimensions (Effective Management and Interdisciplinary Relations; Sustained and Autonomous Practice; Consent and Professional Communication; Recognition Team Health, Training and Education) that constitute the scale, levels of empowerment by percecionados Nurses Specialists Nursing Maternal Health and Obstetric remains too low for them all, and is in the dimension 'Sustained and Autonomous Practice', which concerns the monitoring, support theory and practice on the exercise of clinical nurse specialists and defend the real interests of parturients who analyzed the lower levels of empowerment (Md = 19.00; xmax = 20.00). The sheer 'Effective Management and Interdisciplinary Relations', we see the same way, the level of empowerment percecionado by specialist nurses is low (Md = 33.00; xmax = 45.00), which also happens to the dimensions' Communication Professional and Consent '(Md = 8.00, xmax = 10.00), and' Education and Training '(Md = 4.00, xmax = 5.00). It is interesting to analyze what is the dimension 'Team Recognition Health', which relates to the recognition of the professional nurse specialist in maternal health nursing and midwifery by the medical profession, we find that a higher level of empowerment (Md = 3.00; xmax = 5.00).

Regarding the level of empowerment by Nurses in their study, Fernandes (2004), the results presented by this investigator will not meet our, as in the case of aspects related to 'Sustained and Autonomous Practice', nurses participated in the investigation show great empowerment in the delivery of their care and support of these theoretical and practical (Fernandes, 2004).
We concluded that the pursuit of fundamental studies in the area of empowerment in nursing. Only by examining the practices that empower nurses is that we can contribute to the future of midwifery in Portugal

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