Empty nest syndrome: A concept analysis

Abstract

BACKGROUND:

Empty nest syndrome (ENS) is parents’ experience to their children leaving home. Considering the lack of a clear definition of this concept and its context-based nature, this study aimed to define the ENS concept.

MATERIALS AND METHODS:

A three-phase concept analysis using a hybrid model was used. In the theoretical (first) phase, a literature review was conducted using Scopus, WOS, PubMed, ProQuest, Irandoc, Research.idml, Magiran, and SID, with the search terms “empty nest syndrome,” “aged,” and “middle-aged,” and their synonyms, with no time and language restrictions until the end of 2021. After the screening, 29 relevant articles entered the study. According to the findings of the first phase, the fieldwork (second) phase was directed using the qualitative content analysis approach, and semi-structured interviews were conducted with nine elderly and middle-aged individuals with an open-ended question. Results from both were included in the final (third) phase.

RESULTS:

The theoretical phase created an operational definition to guide the fieldwork phase. The fieldwork phase resulted in the emergence of six themes. The final analysis phase formulated a comprehensive definition of this concept: “ENS is a subjective phenomenon that occurs as a result of parents’ reaction to their children leaving home.” This transition from crisis to self-regaining includes the stages of mourning or resistance reaction, feelings of loss or passive behaviors, sublimation or impulsive behaviors, adaptation, and relief. It initiates with the last child’s departure and continues until two years.

CONCLUSION:

Exploration of the concept of ENS can be the basis for designing a model or theoretical framework, devising measurement instruments for the concept and its consequences, and developing programs to increase the healthcare team’s awareness to identify the problem and conduct appropriate preventive or therapeutic measures.

Introduction

The family life cycle includes two stages of development and shrinking of the family.[1] The transition to the empty nest period, when the child/ren leave their paternal home, is a typical event of the developmental stage.[2,3,4] Parents show different reactions to the departure of their children, which is associated with various symptoms called empty nest syndrome (ENS).[4,5,6] Different adverse conditions, health-related issues, reduced performance capacity, and psychosocial concerns, including loneliness, anxiety disorders, changes in social support, and reduced quality of life, are among the ENS-related problems.[7,8,9] On the other hand, some studies have demonstrated that people with an empty nest are more satisfied with life,[7,8,10] and it can be a favorite time for parents.[7]

Considering the shrinking family size, the short interval between the birth of children, and the increased life expectancy, which has made the empty nest period longer,[11] some problems related to middle and old age arise that require appropriate interventions from healthcare policymakers and planners.[12] They include knowing the behavior patterns and lifestyles to reduce the burden of diseases and loneliness-induced complications and saving money for various ENS-caused health and treatment problems.

Despite the research conducted regarding the features of ENS and measurement methods, there is no clear, comprehensive, and agreed-upon definition for it. On the other hand, considering that ENS is a contextual concept, its definition, attributes, and consequences may be influenced by the cultural and social characteristics of the context. Hence, defining the concept requires further investigation to explain the dimensions affected by the context and identify the concept’s theoretical foundation and attributes through a comprehensive literature review.[13] The present study tries to elaborate on the concept of ENS using the hybrid model.

Material and Methods

Study design and setting

This concept development study was conducted based on Schwartz–Barcott and Kim’s hybrid model (1986) in three phases: theoretical, fieldwork, and the final phases [Figure 1].[13]

Figure 1.

Illustration of the development method concept

Theoretical phase

Selecting a concept

An interesting concept was selected.

Searching the literature

A comprehensive literature review was performed to identify the attributes, antecedents, consequences, and definitions of the desired concept, which resulted in an operational definition to enter the fieldwork stage.[13,14] A systematic search with appropriate syntax was conducted to collect the data based on purposive sampling from the dictionaries and all available international databases, including Scopus, Web of Science, PubMed, and ProQuest, along with national databases, including Irandoc, research.idml, Magiran, and SID. The search terms “empty nest syndrome,” “aged,” and “middle-aged” and their synonyms were used with no time and language restrictions until the end of 2021. To retrieve other related articles, Google Scholar was searched, the records were saved in a general file of Endnote software, and 378 articles were found in the initial review. However, 29 articles entered the study after meticulously examining the articles based on the purpose of the study and removing the duplicates and irrelevant articles [Figure 2].

Figure 2.

Literature search and selection process

Dealing with meaning and measurement

The full texts of the articles were fed into the MAXQDA10 software. Then, the data were analyzed using the content analysis method based on the Elo and Kyngäs approach (2008) in three stages: preparation, organization, and reporting. The text of each article was read several times, and the concept attributes, antecedents, and consequences were extracted. Then, the codes were classified into subcategories based on similarities and differences. Finally, the subcategories were formed and labeled based on the similarity of integration and categories.

Choosing a working definition

An operational definition was presented to enter the fieldwork phase by classifying and analyzing the data and comparing and highlighting the existing definitions related to the initial definition.[12]

Fieldwork phase

At this stage, a qualitative study with participants was conducted to examine the concept.

Setting the stage

According to the initial review, the context where the expected attributes of this concept would become apparent was identified. Therefore, the Comprehensive Health Centers in the Golestan Province were selected as the interview setting [Table 1].

Table 1.

Studies reviewed for data extraction in the theoretical phase (n=29)

Authors/Year/Country	Attributes of ENS
Mitchel and Lovegreen (2009) Canada	Parents' reaction to their child/ren's home leaving, a life course transition, the feeling of loss, depression, being a process, feeling of losing the parental role, identity crisis
Harkins (1978) USA	Identity crisis, being transitory, being a process, being subjective, a transitional state whose effects disappear two years after the event.
Chang et al. (2016) China	Psychosocial problems, including loneliness, depression, and anxiety
Kearney (2002) USA	A transitional stage of life, being a process, creating a crisis, an emotional reaction such as grief, denial, a sense of emptiness, loneliness, loss, mourning, and longing
Badiani and DeSousa (2016) India	A set of long-term negative mixed emotions with weak effects on the person or the marital relationship, such as anger, depression, anxiety, sadness
Raup J and Myers (1989) USA	An incompatible and abnormal response to the transition to the post-parental period, including loss, grief, and depression
Zhang et al. (2020) China	Negative feelings of parents, especially depression
Barber (1989)	Negative responses to the departure of child/ren, such as feelings of worry, dissatisfaction, loneliness, and depression
Sing and Dubey (2017) India	A sense of emptiness, sadness, sorrow
Mbaeze and Ukwandu (2011) Nigeria	A pathological disorder in response to the departure of all child/ren, A feeling of losing the parental role, depression, loneliness, sadness, and mourning
Wang et al. (2019) China	Negative feelings and psychological problems, such as loneliness, depression, anxiety, pessimism, and other cases, mainly caused by the lack of receiving long-term affection and emotional support from child/ren
Mansoor and Hasan (2019) Pakistan	A transitional stage of life accompanied by unpleasant feelings and adverse emotional disorders, such as mourning, loss, a sense of emptiness, and aimlessness
Bouchard (2014) Germany	Transitional stage of life, post-parental period, negative emotions, and parent's adjustment problems
Bougea et al. (2019) Greece	Transitional stage of life, the parent's response following the loss of the parental role
Gao et al. (2017) China	Anxiety, despair, and depression
Clelland and Chaytors (1981) Canada	Parent's response to the loss of the parental role following the departure of their child/ren, such as restlessness, depression, and dissatisfaction
Liang and Wu (2014) China	Physical and mental problems of the elderly
Ling Lv et al. (2012) China	Psychosocial problems of parents, such as loneliness and depression
Mehdiyar et al. (2014) Iran	A feeling of loss and painful consequences
Mitchell and Wister (2015) Canada	Increased emotional and physical reactions
Murphy et al. (2012) USA	Adverse and traumatic reactions following the loss of the maternal role, leading to the loss
Satori & Zilberman (2008) Portugal	The suffering and hardship of parents, being subjective and person-specific
Su et al. (2018) China	Mental health problems, including hopelessness, loneliness, and depression.
Wang et al. (2017) China	Loneliness and Depression in the elderly people
Zhai et al. (2015) China	Parents' reaction to losing the primary parental role
Gong et al. (2017) China	Loneliness and parental depression symptoms
Ebrahimi et al. (2018) Iran	Depression, anxiety, and loneliness
Liu et al. (2008) China	Feeling depression and loneliness
Viovenica Bongyoga1 Widya Risnawaty (2021) Indonesia	feelings of sadness, loss and loneliness, loss of identity, feelings of isolation, changes in the role of parents, differentiate one family from another, changes in emotional well-being

Negotiating entry

This stage focuses on developing the participant inclusion criteria obtained through a literature review.[13] The inclusion criteria encompassed the middle-aged and aged individuals whose children had left home due to education, work, migration, marriage, or becoming independent during the last 6-36 months, excluding those whose children left the parents due to unpleasant events such as death or hospitalization in a healthcare center. Moreover, those with the ability to communicate verbally in Persian, a high level of consciousness, and no history of psychiatric illness or psychological disorders entered the study.

Selecting cases

The individual level of analysis was considered in the fieldwork phase. Thus, nine middle-aged and aged individuals entered the study. The demographic characteristics were regarded in selecting the samples to have maximum variation. Additionally, due to the overlap of the study concept with other alternative concepts, besides choosing a model case, a related case, a borderline case, or a contrary case can help the researcher determine the attributes of the study concept.[13] Hence, Wilson’s (1969) typology was employed to select the analytical unit.

Study participants and sampling

Nine aged and middle-aged individuals, including a model case (Pl), a related case (P9), and a borderline case (P3), with a mean age of 61.1 years, participated in the study [Table 2].

Table 2.

Characteristics of participants in the fieldwork phase (n=9)

Participants codes	Gender	Age (years)	Marital status	Education level	Number of child/ren	Reason for the child/ren's departure
Pl	Female	45	Divorced	University	1	University
P2	Female	50	Married	University	2	Marriage/University
P3	Male	53	Married	University	1	Work
P4	Female	68	Widow	Illiterate	4	Marriage/work
P5	Male	61	Married	Middle school	4	Marriage/work
p6	Female	73	Married	Illiterate	4	Marriage
P7	Male	80	Widower	Elementary school	7	Migration to overseas/marriage
P8	Female	58	Married	High school	3	Marriage/work
P9	Male	62	Married	University	1	Marriage

Collecting and analyzing data

Semi-structured and in-depth individual interviews were conducted until data saturation to collect the data. Each interview took 40-92 minutes, and the sessions ranged from 1 to 3. With participants’ permission, interviews were recorded and transcribed verbatim immediately after each interview. At this stage, theoretical, observational, and methodological note-taking were used to collect the data, which served as a guide in data analysis. Finally, written informed consents were obtained from all participants and a code from 1 to 9 was assigned to each person.

The interviews started with an open-ended question: “Please talk about your life after your youngest child left home.” Then, further questions were asked based on the participant’s responses to explore different dimensions of the concept, such as “What do you mean by this?” and “Can you explain more?” Finally, at the end of the interview, they were asked if there were anything else they would like to add or explain.”

Data were collected from June to November 2022, and the data analysis was performed simultaneously with data collection using MAXQDA10 software. The fieldwork phase was directed based on the findings in the first stage using a qualitative content analysis approach. The initial analysis results were discussed with the participants to clarify and describe the ideas expressed in the interviews. After frequently examining the data, the relevant codes were assigned to the predetermined categories and new categories were created for the remaining codes.

Final analytical phase

In the third stage, the data from the previous two phases were compared to achieve a precise and comprehensive definition of the concept.[13,15,16] During this stage, a step was taken back and the findings were re-examined focusing on the initial definition of the concept. This stage was finished by weighing the data, working with them, and writing the results. Organizing the data freely and reconsidering the data obtained from the theoretical and fieldwork phases were performed using methodological notes. Finally, a comprehensive definition was presented encompassing all the extracted attributes.

Methodological rigor

Lincoln and Guba’s criteria[5] were used to ensure the trustworthiness of the study findings. Dependability was achieved through member checks; the concepts were checked with the participants to ensure they agreed with the extracted idea. To meet the credibility, long-term participation took place in the research context and sufficient time was allocated for data collection. Regarding confirmability, the data were continuously recorded and three nursing professors were consulted to confirm the initial codes, categories, and subcategories (peer check). Finally, a comprehensive description of the study context and the participants was provided to permit the audience to make an accurate judgment about the transferability of the findings.

Result

The results are presented under the headings of theoretical phase, literature review, working definition, and measurement.

Theoretical phase

At this stage, 825 codes were extracted and classified into 17 separate categories based on their meanings (i.e. attributes, antecedents, and consequences of the concept) and measurement methods [Table 3]. According to the classification and analysis of these data, an operational definition was formulated for the fieldwork phase.

Table 3.

Categories created in the theoretical and fieldwork phases of ENS concept analysis

	Categories created in the theoretical phase	Categories created in the fieldwork phase
Antecedents	- Child/ren leaving home/child/ren's independence - Psychological vulnerability	- Codependency to child/ren
Attributes	- Parent's response to child/ren's departure - Change in parental role - Transitional phase of life - Being a process - Transience - Being subjective - being individual	- Trying to maintain the parental role - Emptying without a replacement
Consequences	- Self-doubt - Self-care changes - Physical-psychological syndromes - Loss of zest for life - Conflicting emotions - Changing communications - Economic effects - Support changes	- Regret for the past - Longing to see their child/ren - Concern for compensating for the past

History and definition of ENS

After Hill and Hansen introduced the empty nest theory in the 1930s, Gorelick included the empty nest as one of the six stages of family life in a 1949 study. In 1965, ENS was defined as the emotional frustration experienced by parents in the empty nest stage. Dorothy Canfield first presented the ENS concept in 1914; however, it was clinically identified and became common in the 1970s as a group of symptoms, including depression, loneliness, and low self-confidence, among mothers whose last child had recently left home.[17] ENS is defined in dictionaries as emotional distress or sadness in parents whose children have grown up and left home.[18,19,20]

Literature review

The literature review shows that researchers have presented different definitions for ENS. However, most studies have defined it as the psychosocial problems such as depression, anxiety, feelings of loneliness, and loss that parents display after their child/ren leave home.

Westberg (1971) defined ENS as a sense of significant loss and grief following the departure of children from the household.[18] Similarly, Borland (1982) suggests that ENS is an incompatible response to the transition to the post-parental period, which manifests in response to the feeling of loss.[20] However, Oliver (1977) argues that being stuck in ENS is more about losing the control and power parents have had over the situation rather than losing the children.[21] Many researchers consider ENS, associated with losing the parental role.[22,23,24] Other definitions agree on depression in the empty nest stage as ENS.[20,25,26,27,28] Some studies consider the feeling of emptiness,[29] anxiety, despair,[27,28] parents’ severe inability to cope with the situation,[30,31] and pessimism[32] after the children’s departure equivalent to ENS. Moreover, fear and difficulty redefining roles are characterized by negative consequences, such as alcohol addiction, identity crisis, marital conflict, and depression.[10,33]

These definitions have focused on the negative aspects of this concept; however, other studies define ENS as a set of mixed feelings arising from separation from a child, having a minimal impact on the individual.[34,35] It is a transitional state,[4] and its effects disappear two years following the event.[36] Some studies consider ENS as an emotional burden phase that people experience differently, regardless of positive or negative aspects.[23,37,38] Table 1 lists the attributes of ENS in the theoretical phase.

Working definition

According to the existing definitions and the extracted attributes from the literature, ENS was defined as “a subjective phenomenon that arises as a result of parents’ reaction to their child/ren’s independence and departure from home. It initiates with the last child’s departure and continues until two years. These unique reactions can manifest as changes in parental roles and emotional-behavioral changes”.

Measurement

Investigations showed that there are two ENS scales. The ENS Scale in Susanti’s thesis (2008) includes emotional reactions such as grief, emptiness, loneliness, loss, lack of zest for life, being passive, and inability to engage in positive activities, and difficulty concentrating and establishing relationships. It consists of 57 items and is scored based on a four-point Likert scale from strongly agree to strongly disagree.[39] On the other hand, Mbaeze and Ukwandu (2011) employed a scale on the feelings of the older adults in ENS, consisting of 16 items scored based on a five-point Likert scale from strongly agree to strongly disagree.[40]

Fieldwork phase

In the fieldwork phase, 432 extracted codes from the interview were analyzed and classified into 17 categories resulting from the theoretical framework. Additionally, six new categories were added because some codes did not fit the existing categories [Table 3]. Finally, the categories were merged and condensed through an induction process, resulting in 6 themes and 16 sub-themes [Table 4].

Table 4.

Themes and sub-themes extracted in the ENS concept analysis

	Themes	Sub-themes
Antecedent	A slow birth of a crisis	Being unprepared for child/ren's departure The short period between child/ren's departure self-deception
Attributes	A mixture of pain and pleasure	Comfort with suffering Bittersweet experience
	Life without vitality	A sense of loss Longing
	Emptying without a replacement	The maddening silence of the house Being swallowed by the house Emptying house
Consequences	Getting lost in the path of life	The bitter feeling of being forgotten The feeling of being rejected The feeling of being a burden
	Make changes to maintain consistency	Adaptation mechanisms Changing lifestyle Striving to revive interests

Themes

A slow birth of a crisis

Some participants were unprepared for their children’s departure and experienced a crisis that made the transition from the empty nest process difficult: “I was so busy with my children that I don’t know how to live without them” (p5). “Everything happened suddenly, and I had no prior plan for this situation. I got it when they left, and I don’t know what to do without my children” (p2). “I have much spare time now and I often ask myself what I should do when the children aren’t here” (p6).

The mixture of pain and pleasure

The participants experienced conflicting emotions after their children left home:

“I have more free time, but I don’t think it’s necessarily a good thing because you feel the empty place even more.” (p2)

“The departure of the children was a bittersweet experience. I felt relaxed, but I didn’t want to be alone” (p8).

Life without vitality

Some parents admitted that their lives had become empty and joyless after their children left home:

“I feel like the joy has gone out of my life, and it’s as if my life is over” (p4).

“When your child leaves, the joy goes out of your life, and it’s like going back to your single days after university, an uncertain and turbulent period” (p2).

Emptying without a replacement

The departure of children was an irreparable loss for many of the parents, and their lives took on a new path:

“When the house became empty, it was tough for me to stand it, especially in the evenings. It was as if nothing and no one could fill their places” (p2).

“After my children left, it was as if I was swallowed by the empty house” (p6).

“My home was empty, and it made me crazy. My life became completely different” (p7).

Getting lost in the path of life

Some participants expressed concerns about being forgotten by their children:

“I felt like my children didn’t need me anymore. It was very tough and bitter for me to feel forgotten” (p8).

“I can’t imagine my children forgetting me. I can’t bear it “(p4).

Make changes to maintain consistency

Some gaps arise when children leave home; therefore, parents must plan for this issue: “When my children left me, I felt very lonely, and I had much free time. With proper planning, I filled these time gaps. Even though I felt dependent on them, I decided to let them go and live their own lives. I had to change my lifestyle” (p2).

“This is the natural process of life, and we must cope with it. It’s something that eventually happens. What is important is prevention and coping mechanisms. We need to resolve this problem to feel less loss” (p3).

“Although I was so sad when my son left, I found myself after a while. I expanded my work; now, I go to the office early in the morning and to the gym in the afternoon. I go walking and return home and go to bed at ten. The next morning, I start the day again” (p1).

Analytical phase

The fundamental attributes of ENS, frequently referred to in most literature and emphasized in the fieldwork, include parents’ response to their children’s departure, changes in the parental role, a transitional phase in life, a process of transition from crisis to self-regaining, and being transience, subjective, and individual. The findings indicate that ENS is a process that occurs in five consecutive stages, and each phase emerges before the next stage; however, all individuals may not experience all stages [Figure 3].

Figure 3.

The process of ENS

The final definition of ENS

Based on analysis of the literature review and fieldwork, the ultimate definition of ENS is: “ENS is a subjective phenomenon that arises as a result of parent’s reactions to their child/ren leaving home. This process, a transition from crisis to self-regaining, includes stages of mourning or resistance reaction, feelings of loss or passive behaviors, sublimation or impulsive behaviors, adaptation, and relief. This process initiates with the departure of the last child and lasts for a maximum of two years. These unique reactions can manifest as behavioral and perceptual-emotional changes.”

Discussion

The hybrid analysis results show that ENS is one of the most significant concepts in the human life course. Different conditions of parents and children, including some physical, psychological, and demographic characteristics of individuals, influence how they react to their children’s departure,[10,18] the reason for the child’s departure,[18] the parent–child relationship, chronic illnesses,[20,27] and concurrent stresses such as retirement and hormonal changes.[40]

Most researchers have considered ENS a pathological issue.[5,16,20,41,42] However, as stated in the syndrome definition, a syndrome consists of symptoms, signs, a predictable and identifiable pattern of behavior, actions, etc., that occur in specific situations.[19] The qualitative and quantitative results of this study indicate that ENS is not inherently pathological, although it changes into a clinical pathological diagnosis in case of an unadaptable parental response to their children’s departure. This finding is consistent with studies that have referred to ENS as a parental response to their children’s leaving.[2,4,18,42]

Consistent with various studies, this study’s results show that ENS is a process[43,44] that occurs differently in different individuals; some easily accept their children’s departure, whereas others show severe emotional and behavioral reactions. Not all stages of ENS may occur in individuals; that is, an individual may go through all phases, whereas others may reach acceptance and adaptation at the onset. The first stage occurs when all children have left home. Therefore, a parent enters a mourning phase and may exhibit symptoms, such as mood changes, crying, anxiety, loneliness, sadness, depression, distress, isolation, and other symptoms, or they may enter a phase of denial and non-acceptance. This finding is consistent with the autumn season of Clelland’s Season of Change Theory.[45] Autumn is when change begins, and the tree leaves turn yellow and start falling off and parents enter a new stage of life and must spend days without their children, whom they have raised.

Based on the result of the fieldwork phase, the second stage of this process is characterized by a sense of loss or passive behaviors, accompanied by symptoms such as a feeling of loss, a feeling as if the world has fallen apart, a feeling like there is no return, feeling like the child has died, a sense of a void in oneself, or feeling indifferent, confused, and uninterested in different issues. Winter is the same in the Season of Change Theory. Cold and depressing winter during which parents are confused, and the winter solstice begins. Parents’ minds should be open to new insights and opportunities.[45]

In the third stage of sublimation or impulsive behavior, the individual undergoes a process of progress and improvement by expanding their business, continuing their education, learning new arts and professions, and participating in social activities. In contrast, they may exhibit impulsive behaviors such as overeating, anger and irritability, excessive shopping, over-preparing food, exaggerating problems and difficulties, restarting smoking, trying to distract themselves, or releasing their emotions. The sublimation phase is consistent with the spring, a time of growth.[45] It is the time when the parent should seek new insights and create a new life. After experiencing the first emotions and the child’s departure, parents should be able to find a new way of life for themselves.

The fourth stage of the ENS process is adaptation. Parents realize the need to take care of themselves. Therefore, they try to adapt to the new situation to prevent harm to themselves and their children. Parents accept that their children’s departure is a normal part of life and cope with it.[4]

In the fifth stage, the relief stage, parents are expected to feel a sense of joy and happiness with greater peace of mind from the fruits of their efforts. The fourth and fifth stages correspond to the summer. It is the time to celebrate and enjoy all the achievements. Kearney (2002) referred to an eight-stage process by Schaffer and Wasserman; the 7^th and 8^th stages correspond to the 5^th stage in the present study.

One of the emerging themes was the slow birth of a crisis. The results of some studies showed that parents prepared for their children’s departure are less likely to experience emotional crises. Parents become more adaptable to their children’s departure over time, and their emotional and behavioral symptoms decrease or disappear. Therefore, time is essential in creating this adaptation; it is not present in simultaneous or very close children’s departures. Some parents have a morbid self-dependence on their children. This can lead to a crisis after their children’s departure, which is consistent with Kearney’s study.[46]

Another emerging theme from the interviews was emptying without a replacement. Most participants used the phrase “being swallowed up by the home,” a common term in northern Iran, to describe the highest level of loneliness and the desire to escape from home. In her interviews, Kearney (2002) discussed the awkward silence and the empty house.[46,47]

Life without vitality is accompanied by concepts such as the feeling of loss and longing. A sense of loss is a sensation that most studies have addressed.[45] In addition, a study has also discussed parental longing to see their children.[45]

Another finding was the mixture of pain and pleasure. In a study, parents reported simultaneous feelings of comfort and guilt after their childrens departure.[11] Some researchers have unilaterally viewed ENS and regarded this syndrome as equivalent to negative reactions; however, some researchers have focused on the positive consequences of the syndrome. On the other hand, other researchers have tried to eliminate the black-and-white thinking and see ENS as a set of symptoms. Therefore, it is a set of positive and negative reactions of parents in response to their children’s departure. These emotions can be a mixture of joy and sorrow, and anxiety and peace.[5,17,48]

Getting lost in the path of life is another theme that emerged. This finding is consistent with Tian (2009), demonstrating that parents with an empty nest feel their children have forgotten them.[46] Furthermore, Hobdy et al.[49] (2007) showed that parents think their children do not need them when they leave home, causing emotional harm to them.

The theme of making changes to maintain consistency emerged from interviews. A study showed that using positive adaptation mechanisms to prevent depression in empty nest parents is effective.[48] After the children’s departure, parents need to adapt to a new lifestyle.[49] Clelland labels this period as a time of change and coping.[45] Additionally, several studies have shown that parents can enjoy more freedom and have more time to indulge in activities they are interested in after their children’s departure.[42,43,44]

Strength and limitations

The strength of this study was using both quantitative and qualitative methods, which provide a comprehensive definition of a context-based concept. However, among the limitations as with most qualitative research, the results of the second phase are not generalizable to all settings.

Conclusion

The study findings comprehensively define ENS based on theoretical foundations and fieldwork. This definition can be the foundation for developing a model or theoretical framework and developing programs for increasing healthcare teams’ awareness to identify the issue and implementing appropriate preventive or therapeutic measures. In addition, according to the results of the hybrid concept analysis that led to the formation of the ENS stages, devising measurement instruments to assess the ENS for screening of these stages in affected people can be a step towards preventing the unfortunate consequences of this syndrome.

Financial support and sponsorship

The Research Deputy of Golestan University of Medical Sciences.

Conflict of interest

There are no conflicts of interest.