1. Theoretical framework

The phase in the family life cycle when adult children leave their parents’ home is called “family with adult children” (^{Relvas, 1996}), “launching the children and moving on” (^{Carter & McGoldrik, 1995}), or “empty nest.” This phase is characterized by recognizing the adult state and independence of the children, which leads to the expression of emotional ambivalence and demands the renewal of conjugality (^{Thapa et al., 2018}).

The term “empty nest” is not consensual. Its conceptualization, in the 1930s, expressed a depressive dimension of family life, not very favorable to its necessary restructuring (^{Relvas, 1996}). Nevertheless, the term has taken root in the literature. Today, the empty nest is discussed according to two perspectives: the pathological, associated with a depressive state, and the positive transformative, related to the renewal of marital life.

Considering the pathological perspective, empty nest syndrome is a psychological condition that affects both parents when their children leave home. It is characterized by the experience of feelings of grief, loss, fear, helplessness, difficulty in adjusting to new roles, and changes in parental relationships (^{Bougea et al., 2019}). This phase can be emotionally difficult for parents who experience feelings of sadness, loneliness, and insecurity, as their children’s independence can cause changes in their lives (^{Kaur & Kaur, 2021}).

On the other hand, in its transformative perspective, the empty nest can be an exciting experience for the couple, becoming an enriching, productive, and creative transition which revives their relationship. It is an opportunity for reconnection, a time for renewing old friendships and hobbies, rekindling interests, continued personal growth, self-acceptance, and improved quality of life (^{Bougea et al., 2019}; ^{Fonseca et al., 2022}; ^{Kaur & Kaur, 2021}).

Understanding their children’s departure as a new adventure for development, rather than a loss, will help parents work through the absence of their child(ren) from their home and learn to cope with the void associated with the so-called empty nest syndrome (^{Kaur & Kaur, 2021}). However, significant challenges are posed to the ability to resume or renew marital intimacy, possibly overshadowed by the parental role and lost over the years (^{Thapa et al., 2018}).

Marital satisfaction relates to relationship stability, strategies to manage differences, quality of daily interactions, respect, admiration, and gratitude for the spouse, fostering acceptance, appreciation, and trust (^{Chaskelmann, 2020}). Thus, empty nest couples need to share their innermost feelings, support each other, and physically and emotionally care for one another to reconnect in their conjugality (^{Thapa et al., 2018}).

However, some studies argue that there is no significant change in couples’ lives after their nests are empty (^{Fonseca et al., 2022}).

Through their therapeutic interventions, nurses help families develop interaction patterns adequate to the changes experienced throughout the family life cycle and adopt more efficient and effective coping strategies. The Nurse Specialist in Community Nursing in the area of Family Health Nursing is responsible for carrying out interventions that promote couples’ empowerment to cope with the challenges of family life cycle transitions, thus reducing their negative impacts.

The Dynamic Model of Family Assessment and Intervention (MDAIF) is an interactive and flexible model with a multidimensional approach focused on family interactions and the complexity of the family system. It allows identifying families’ needs and resources, establishing priorities, and planning and implementing interventions. It also encourages families’ participation in the whole process to find solutions that promote change and restore families’ healthy functioning, thus strengthening the family unit (^{Figueiredo, 2012}). Figure 1 illustrates the MDAIF and its three evaluation dimensions, which are essential and relevant in delivering nursing care to families.

Studies on nursing interventions facilitating the transition in the family life cycle when children leave home are scarce. Therefore, it is essential to know families’ development and functioning to ground Family Health nurses’ interventions.

2. Methods

2.1 Sample

This is an exploratory-descriptive qualitative study, with the participation of 16 individuals forming eight couples in the empty nest phase. The sample was non-probabilistic and recruited using the “snowball” sampling technique (^{Coutinho, 2022}) until data saturation was reached. The inclusion criteria were to be a heterosexual couple with children, married or in a de facto relationship, with an empty nest for more than six months. Couples with at least one child at home were excluded.

All ethical principles were met, and the Ethics Committee of the Health Sciences Research Unit approved this study (opinion no. 704/ 09-2020).

2.2 Data collection tools

Data were collected through semi-structured interviews, developed through a script with four open-ended questions and one question for sociodemographic characterization. During the interviews, these questions were complemented to allow for greater flexibility and freer and non-standardized data collection (^{Coutinho, 2022}). The audio-recorded interviews were conducted individually to avoid participants feeling embarrassed about their answers. Due to couples’ preference, the interviews took place at their homes between December 2020 and February 2021, following the COVID-19 prevention measures. The interviews were transcribed in full and content analysis was performed (^{Bardin, 2018}). The participants’ language was respected in the transcription, and conventions were used to record comments, interpolations, pauses, and silences.

2.3 Data analysis

The MDAIF (^{Figueiredo, 2012}) was used to analyze and organize the data into areas of attention, operational dimensions, categories, subcategories, and record units, considering their similarities and the thematic convergence of the content of the narratives, thus achieving the results and allowing their discussion.

The characteristics of the MDAIF and its dynamic, flexible, collaborative, and interactive nature make it essential for knowing, assessing, understanding, and caring for families as a unit of care within PHC and Family Health Nursing and justify the choice of this theoretical framework.

Two outside judges, experts in the categorization system, validated the analysis, adding rigor to the study.

3. Results

Considering the MDAIF (^{Figueiredo, 2012}), the presentation of the results begins with the “Structure” dimension, identifying the family composition, family type, and extended family.

The study sample consisted of eight heterosexual couples who made up the household, married or in a de facto relationship, between 32 and 50 years old. The women’s mean age was 61.9 years, and the men’s was 66.3 years. Half of the couples had one biological child (50%), and the other half had two biological children (50%). Of the couples with two children, one had a deceased child. The couples had been in an empty nest for a mean of 8.1 years (between 15 months and 14 years).

Next, the presentation of results continues with the “Development” and “Functioning of the family system” dimensions and their areas of attention, operational dimensions, categories, subcategories, and record units. The “Development” dimension allows understanding phenomena related to families’ growth and evolution in their life path (^{Figueiredo, 2012}). The areas of attention “Marital Satisfaction” and “Parental Role” were identified in this dimension, as shown in Figure 2.

Marital Satisfaction focuses on the marital processes associated with the continuity of a satisfying relationship, understood as supporting the various interconnected aspects (^{Figueiredo, 2012}). In this dimension, the participants’ discourses focused on the following operational dimensions: Relationship Dynamics, Couple Communication, and Sexual Interaction. There were no narratives on sexual function, as illustrated in Figure 3.

In the operational dimension “Relationship Dynamics,” the category “Sharing of household chores and responsibilities, role flexibility” shows couples’ reorganization after their children’s departure - “Yes, in fact, I share more tasks now than before” (H2), or their maintenance of daily routines and responsibilities - “Tasks were already shared ... our routines stayed the same” (H4).

The category “Possibility or how each one expresses their feelings regarding their spouse” shows evidence of favorable aspects - “It’s just the two of us ... we are more united ...” (M5); “Our word is unity (...) there is always that void, and we have to be more and more united” (H4).

Couples mentioned that after their children left home, the time spent together was a source of satisfaction - “We have more time, I have more time for him and he for me.” (M5), for shared interests and joint activities - “(...) hikes and walks, everything with him, together.” (M2). However, although without harming the couples’ relationship dynamics, some narratives pointed out signs of dissatisfaction - “It is true that she sometimes ... is more evasive than me or more than I would like ... Maybe I would even like to go for walks, but she prefers to stay... at home” (H7).

Still, in this category, it is possible to observe that the Covid-19 pandemic impacted the participants’ conjugality. It forced them to do more activities at home, or in its vicinity, and to socialize less - “... normally when I went shopping, he would always go with me, now with Covid, he doesn’t. Normally he doesn’t want to go, because of the pandemic (...)” (M6).

In the operational dimension “Couple Communication,” the category “Tolerance for differences of opinion” was identified - “... it is true that sometimes we disagree with each other, but it can be solved, most couples have these things...” (H7).

The category “Satisfaction with the established communication pattern” was identified in some participants’ narratives - “... today, looking at the situation, we are certainly closer to each other, we talk a lot more ...” (H7). However, not all participants expressed this satisfaction. Some reported changes due to the lack of dialogue - “Sometimes I think we don’t talk enough, we sometimes run away from certain situations, and we bypass them (...), to avoid conflicts” (H6).

Understood as the relationship attributes that include the values and attitudes related to the expression of sexuality (^{Figueiredo, 2012}), the operational dimension “Sexual Interaction” was organized into four categories presented below.

Considering the category “Expectations and beliefs about sexuality,” one of the couples identified differences regarding sexuality. These differences were attributed to the lack of affection in the spouse’s family of origin - “... I don’t know if it has something to do with the way he was raised (...) his parents were very cold people and never knew how to give love and I was raised poor, but with a lot of love (...)” (M7).

In the category “Expression of affection in intimacy,” the narratives revealed satisfied participants - “... Intimately, I think we are more open (...) closer to one another...” (H6). However, some participants mentioned that intimacy with their spouses had become less expressive - “In terms of affect (...) it broke a bit. Not for her but for me (...)” (H3).

Concerning the category “Opportunities for intimacy related to resources (time, space, privacy),” the analysis showed differences of opinion among spouses. Female participants denied changes - “In terms of time, willingness, exchange of caresses? .... No, I don’t think so, it hasn’t changed at all” (M6). On the other hand, the male participants reported an improvement in their intimate relationship - “things have changed... we have more freedom... we feel more at ease...” (H6).

Finally, the “Frequency of sexual intercourse” was influenced by aspects inherent to each spouse and not directly attributed to their children’s departure - “In terms of married life, it has more to do with the couple’s disposition (...) the changes that may occur are also related with age, disposition, tiredness... It’s not the children’s departure” (M2).

Still, within the “Development” dimension, the area of attention “Parental Role” refers to the family roles characterized by the family members’ behavioral patterns regarding their expectations and beliefs about the role resulting from the functional model of the system and the cultural factors underlying it (^{Figueiredo, 2012}). The content analysis revealed narratives only in the operational dimension “Family adaptation to children’s departure” and its categories, as shown in Figure 4.

Several phases were observed in the category “Redefinition of the relationships with their adult children” and differentiated according to the accounts of the moment of transition. The phase immediately after the children’s departure seems to have been experienced as an empty nest. Nevertheless, as time went by, the feelings were overcome, revealing a balanced adaptation - “Yes, I missed them, I missed them, I felt sad, a bit of nostalgia, we were alone... but then with time everything goes away...” (H5).

Two subcategories were identified: “The financial support for the children” and “The supportive relationship between parents and adult children.” The subcategory “The financial support for the children” demonstrated that children’s departure from home sometimes implies an increase in parents’ expenses as they help their children financially and with the purchase of essential goods - “... we give her close to 500 euros every month (...)” (H3). In the subcategory “The supportive relationship between parents and adult children,” it is possible to observe relationship reciprocity, concern for the well-being, and mutual help, indicating that the adaptation to this stage was achieved gradually, with the balanced redefinition of roles - “... so [we] the parents are here to help in whatever is needed and then we also count on them” (H4); “If he has any problems, he calls us (...) if we have problems, we call him, and he corresponds to our call, we do the same thing (...)” (H8).

In the category “Integration of relatives by affinity and grandchildren into the family,” the analysis revealed that couples welcomed and accepted all members, facilitating the creation of interactional bonds - “R. is like another son (...) he is an asset” (M5); “They come here with the kids, and we are always playing (...). We have three grandchildren, two twins, and a little girl...” (H5).

The “Satisfaction with the relationship with the children” was evident, even in families whose children were geographically distant - “... even far away he is always present. So much so that the day I shaved my hair he shaved his there! And while talking to me on Facebook.” (M1); “The ties continue, the bonds have not been cut, quite the opposite...” (H7).

The category “Satisfaction with the contact established with the children” was identified and highly valued in the participants’ narratives. The contact softens the void caused by the children’s absence and provides reassurance by proving that they are well - “Very important (...) by how they answer or how I see them through the video call, I know how they are (...) Talking to them, listening to their voice, I can tell right away if they are well or not” (M6).

This category also includes the “Changes in contact with their children due to the pandemic.” For some couples, the pandemic delayed the reunion with their children who emigrated. For others, it prevented them from visiting each other, socializing, and doing activities together - “...but if it was not for Covid, he would already be here, he had everything arranged to come in June but then this delayed everything...” (M1).

Next, the “Functioning of the family system” dimension is presented. This dimension refers to the levels of “... family interaction that allow performing family functions and tasks based on the functional complementarity that supports the system and the values that allow achieving its purposes, through the co-evolving processes that ensure continuity” (^{Figueiredo, 2012}). As shown in Figure 5, the areas of attention identified in this dimension were “Caregiver’s Role” and “Family Process.”

The Caregiver’s Role represents an added responsibility with dependent elderly parents and the consequent need to provide care and/or one of the spouses’ illness. Aging and dependency are relevant issues and represent challenges for the younger generation, whose parents are in their care - “I had my mother sick, my father stayed home alone, and we had to alternate (...) something could happen, right? They needed us...” (H4). By interfering with the functional and self-care ability, the illness of one member of the couple led the spouse to provide all the expected support, with this role being valued and recognized - “He helped me in my illness, without a doubt (...) He was my driver, he was my husband, he was my nurse, he was my everything” (M3).

The “Family Process” operational dimensions are “Family Coping” and “Family Beliefs.” Considering “Family Coping,” only the women mentioned the need for facilitating resources - “I had my time occupied (...), and I had friends, yes (...) we went out for coffee, had tea in the pastry shop” (M3). The category “Family Beliefs” presents the spiritual beliefs and values. The participants demonstrated having accepted and adapted gradually to their children’s departure based on the belief that this was the normal course of life - “Children are only ours when they are little. (...) life is just like that ... children cannot live at home forever, so parents (...) have to think that they have to let go” (M7).

Beliefs about health professionals’ interventions were also observed. Most of the participants recognized that the Family Health nurse could support them in redefining their conjugality. They specified that the Family Health nurse should pay attention to signs of adaptation difficulties in order to intervene - “The nurse (...) could (...) direct us to what we should do to feel better, provide advice (...)” (M8).

4. Discussion

At this phase of the family life cycle, according to ^{Costa (2018}), marital satisfaction is characterized by role redefinition, relationship reconstruction, and continuity of daily activities without significant changes in the couples’ lives.

Living together in conjugality leads to creating habits and routines, requiring an adjustment in perspectives, expectations, and behaviors towards the other. As ^{Porreca (2019}) and ^{Silva et al. (2017}) argue, the ability to renounce, give, talk, and be flexible contributes to balancing the relationship dynamics and strengthening the marital relationship.

The couples’ time provided an opportunity to discover new interests and shared activities, as mentioned by ^{Costa (2018}). The couples under study saw these activities limited by the pandemic phase and confinement. Nevertheless, unlike ^{Silva et al. (2020}), the pandemic did not negatively affect these couples’ conjugality. Some reported becoming closer, using creativity and good humor to overcome adversities. Several authors (^{Falcão et al., 2020}; ^{Kaur & Kaur, 2021}) have described this closeness during the empty nest phase. Thus, it is impossible to attribute it only to the time experienced in pandemic confinement.

Regarding the established communication pattern, ^{Chaskelmann (2020}) notes that those who feel closer to their spouse tend to invest more in the relationship, providing it with stability. Moreover, when faced with conflict situations, the couples’ best strategy, as described in other studies (^{Silva et al., 2017}), may appears to be to avoid the confrontation and exacerbation of marital conflicts, maintain silence and reflect individually in order to understand the partner.

Regarding sexual interaction, each one’s beliefs and expectations and the length of the marital relationship allowed one or both spouses to accept, adjust to, and understand each one’s individuality, corroborating ^{Porreca’s findings (2019}). The expressions of affection and sexuality are experienced accordingly to the individuality and the marital model co-constructed over the years. Thus, the differences found in the participants’ narratives can be considered functional in a marital relationship, as individual and marital subsystems are articulated within a relationship, allowing its development (^{Silva et al., 2017}).

The opportunities for intimacy related to resources (time, space, and privacy) allowed the sexual adjustment and acceptance of each other’s physical changes. They also contributed to increasing marital satisfaction, namely the frequency of sexual intercourse (^{Rocha & Fensterseifer, 2019}). However, following the traditional models, this study’s female participants denied the existence of any differences regarding this topic. In contrast, the male participants reported greater satisfaction with the current availability and space for the couple.

The parental role, very specific to this phase of the family life cycle, proves to be controversial in what concerns the redefinition of the relationship with adult children, as couples’ pride in their children for the autonomy achieved coexists with the concern and sadness due to distance.

Nevertheless, couples adapt to this transition, gradually accepting and reducing the intensity with which they miss their children (^{Kaur & Kaur, 2021}). Also worth noting in this study is the supportive relationship between parents and adult children. As described by ^{Relvas (1996}), the appreciation of interdependence allows sharing difficulties, advice, and experiences and providing assistance at crucial moments in the lives of both. Couples/parents also maintain financial support for their children, constituting a significant source of help (^{Camarano, 2020}). The creation of a space with relationship reciprocity, relationship enrichment versus feelings of abandonment (Relvas, 1996), occurs when the family system opens to grandchildren, sons- and daughters-in-law, and their integration into the family, as confirmed by the couples under study.

The pandemic context caused the participants to feel sad and dissatisfied, which ^{Silva et al. (2020}) and ^{Carmo et al. (2020}) also observed. Nevertheless, it did not cause maladjustments in the parent-child relationship. Families found new ways to adapt, mainly through new technologies, as did other families in the same situation (^{Bung et al., 2020}). The satisfaction with the contact and quality of the relationship with their children expressed by couples can protect them from the empty nest syndrome. Over time, the couples’ feelings of missing their children give way to adaptation through some level of connection between them (^{Kaur & Kaur, 2021}).

While caring for the well-being and autonomy of their children, empty nest couples face increased responsibilities associated with the frailty, illness, or disability of their parents or spouse. One of the family members’ illness may represent a threat to functioning, implying an adjustment in the reorganization process of the family’s structure, roles, and emotional relationships (^{Cunha et al., 2018}). Female participants demonstrated greater family coping skills, which is justified by the cultural association of the caregiver’s role with women.

Couples use spiritual beliefs and values as forms of acceptance that help minimize the impact of adverse, stress-generating events. As mentioned in previous studies (^{Figueiredo, 2012}; ^{Kraus et al., 2021}), these beliefs and values incorporate hope and lived experiences and relate to the search for meaning regarding life events and family continuity as a shared objective and project.

The beliefs about the health professionals’ intervention highlighted the nurses’ role as resource mobilizers and promoters of the potential of the individual and marital subsystems. These professionals were considered guides in the couples’ decision-making. The recognition of the role of Family Health nurses as facilitators of access to health care and their scientific skills (^{Figueiredo, 2012}) emerges in this study as the appreciation and social acknowledgment of these health professionals’ role.

The schematic representation of the results obtained (Figure 6) illustrates a balanced family system, with permeable boundaries with the outside, in harmony with the marital and parental subsystems at the levels of development and functioning. Balance is achieved by interconnecting all areas of attention, operational dimensions and categories, and their influence on each other.