The findings of this study have identified the significance of the social support network for family members in the early period after a close relative has been diagnosed as having lung or gastrointestinal cancer. Our findings verify the definition of social support as a reciprocal exchange of verbal and/or nonverbal information . The main finding in the inductive analysis was expressed through the theme Confirmation through togetherness, which entails being seen and confirmed as a person in one’s new situation of having a loved person with life-threatening cancer in the family, and being respected for one’s experience and knowledge of the sick person’s life situation. The participants indicated that strength was derived from togetherness, from a sense of being an active member of a community and encountering sympathy. The relationship as member of a community is interpreted as more equal than where there is an advocative interpersonal process . The predominant providers of support in the case of the present study were mainly lay persons. Health-care professionals are considered as support when lay persons cannot provide the support that is required , and in this case the advocative interpersonal process may be common.
Validation of our findings through the previous metasynthesis revealed that half of the meanings of social support networks are already well-known from previous qualitative research  (i.e. confirmation, information, encouragement and spiritual beliefs) whilst togetherness, understanding and involvement were not described. One explanation of the discrepancy between these results is that most of the studies in cancer care are based on descriptions of need of social support or interventions from the perspective of professionals [17, 34]). However, the present study verifies that social support is provided mainly by non-professionals, and this may be one reason for the additional meanings found in the study. Another possible explanation is that social support is context-specific and previous research has mainly focused on patients’ need of social support as part of caregiving  whilst the present study focuses on the social support family members receive mainly from lay persons.
The comparison of the findings of our study with the metasynthesis study by Finfgeld-Cornett is a response to existing inconsistent findings in the literature about social support which limit its usefulness in nursing . In nursing science there is also need for more research that can inform practice, and when the issue is complex it is necessary to carry out a chain of studies with different designs before recommendations for practice can be made . During the last five years there have been an increased number of interventions for informal caregivers in cancer and palliative care. It is necessary to continue to focus on mechanisms of intervention, tightly focused aims and outcomes, robust designs and a plurality of models and target populations/settings . Our findings show that networks of significant others (relatives, employer, fellow-workers, etc.) are experienced as meaningful by family members and give them confirmation in their distressing life situation. Characteristic of this situation is that the family member is helping the patient through informal caregiving whilst at the same time trying to prepare themselves for the person’s eventual death . Confirmation lightened the distress and made it easier to deal with the situation [36–38]. Finfgeld-Connett  established that the need for social support has a psychosocial substratum, which was verified in the present study through the antecedents Need of support and Desire for a deeper relationship with relatives. Family members also spoke, though less often, of receiving help with practical matters, which spared them additional distress.
Several steps are needed in the chain of studies  about social support networks. One is to examine nursing intervention to bolster existing networks or to promote the development of new ones . Another step is to develop instruments for use in the evaluation of non-professional social support based on Confirmation through togetherness and the main attributes. Developing measurement instruments  from this expanded conceptual model could encourage nurses and other health-care professional to focus on family members’ personal networks as a way to strengthen mental health. Nurses should reconsider social support as a part of nursing intervention and differentiate social support from concepts such as caring .
In the present study, family members appreciated support from neighbours; it gave emotional relief and strengthened their ties to these neighbours [40, 41]. The findings also revealed that some family members desired a deeper relationship with relatives and wanted to talk to them more. Relatives could not always face their own and the family members’ sorrow. When the family members did not get the support they wanted from relatives, they felt alone and isolated . This feeling of isolation was not experienced in relation to neighbours, fellow-workers, employers and health-care staff. Possibly family members had higher expectations of close relatives with regard to the providing of support.
In addition to the social support network, the person’s own activities to manage the distress are of importance for mental health . A previous study within our larger research project revealed that being with other people is a way of distracting family members’ thoughts. They can think of something else for a while when in the company of friends and co-workers. They find temporary solace and escape from their worries . However, it is important to distinguish between “seeking social support,” which is a theoretical construct of management or coping, and (simply) “social support,” which requires other persons’ willingness to participate in a mutual exchange with the person seeking the support. Management is based on the person’s own appraisal of the actual demands and effort to cope with the current problem . Social support consists of the actions that others perform to assist a particular person [19, 43–46]. The person’s capacity for coping with distress partly depends on the support he or she receives from the family and the social network [20, 42, 47].
Despite the fact that religious beliefs are more common in other countries than in Sweden , the family members in this study derived comfort from spiritual beliefs, through the sense of togetherness derived from sharing Christian belief with friends from church. A similar finding emerged from a study involving four interviews with 20 patients with inoperable lung cancer and their informal caregivers over a one-year period . Many of the patients in their last year of life expressed spiritual needs involving seeking meaning and purpose in life. However, family members also had their own spiritual needs . Incorporating spiritual well-being into health care is essential as existential diversity grows in globalised societies, which means that health-care staff need to be very aware of each patient and family member’s particular needs and must never view anything as just a matter of common sense . When patients and family members were given the opportunity to discuss their spiritual needs with staff, they valued this greatly as it validated their concerns and made them feel cherished . However, patients and family members were often reluctant to take the initiative in raising spiritual issues with “busy” staff. They did not see spiritual needs as directly relevant to the health-care professional’s role, for which reason they actively sought to disregard their spiritual distress . The need for spiritual care was investigated in a study with 156 adult cancer patients and 68 family caregivers. The findings showed that some cancer patients and family caregivers are enthusiastic about receiving some form of spiritual care, whilst others do not want it . However, religion and spirituality are two separate constructs, not interchangeable though sometimes overlapping. Religion, often centrally concerned with spirituality, is also a social phenomenon, characterised by social and cultural concerns and goals. Spirituality is a much broader construct than religion and the two constructs do not overlap for people who are spiritual but do not practise a religion, or indeed for people engaged in religious practices who are not spiritual [52, 53]. Staff require knowledge of spiritual beliefs and spiritual caring, which also implies reflection on and awareness of their own beliefs . Using a theoretical framework and guidelines can better prepare staff to incorporate spirituality into their practice [52, 53].
Family members expressed a need for informational and personal support from health-care staff, which has also been found in previous research . Family members feel confirmed as persons important for the patient if they are listened to and respected by staff [36, 38]. An interesting finding from the present study is that participants found the most supportive persons to be other people with similar experiences. This is an aspect that could be integrated into interventions in health care to great advantage. Furthermore, some participants expressed a need for psychological support for close relatives who could not deal with someone in their family having advanced cancer. This indicates that staff need to apply a family system approach to assist the family . This, in turn, underlines the importance of developing supportive interventions from a preventive perspective at an early stage of the illness trajectory. Research shows that the design of interventions directed towards family members should be based on the specific needs of these people. Support groups using the Internet as a forum to facilitate supportive communication are increasing in number [57, 58]. Interactive web-based programs for cancer patients and their caregivers offer an opportunity to deliver tailored information in an efficient, accessible and cost-effective manner . However, there is an urgent need to evaluate the implemented interventions using valid methods and study designs such as randomised controlled studies, as also to assess lay persons’ provision of social support from the family members’ perspective. At present there is only limited evidence of the effectiveness of support interventions .
This study was limited to exploring the meaning of social networks for family members who are faced with having an adult relative with cancer in the early stage of treatment. Therefore the findings should only be transferred to family members in a similar context. Several limitations must be taken into account when interpreting the findings. One limitation with regard to the transferability of the findings is the small proportion of male participants (4 of 17 participants). The nurses who asked patients to participate were not predominantly male; the patients, however, were mainly male, and all except one chose a female family member to participate. In addition, it is possible that the family member chosen to participate was not the one most dissatisfied with their social support. Gratitude on the part of the family member regarding the possibility of the patients receiving curative treatment, as also deep respect for the health-care professionals’ commitment to helping the patient, may also have influenced the findings. Another limitation is that the data can be presumed to have low stability in that family members’ experiences probably change over time as the illness progresses. The family members in this study were not experiencing high caring demands, as the patients were in the early stage of the illness trajectory. A longer period of illness often means a greater amount of caregiving and as a consequence more isolation, both for the family member and for the patient . Longitudinal research on a similar sample is required for the establishment of greater dependability.
Furthermore, the interview questions in our study were not designed to capture the features of antecedents and outcomes of social support, therefore — not unexpectedly — our findings were not strongly related to the features of the antecedent Social climate and the outcome Improved mental health. This must be kept in mind when comparing the results of the present study with the conceptual analysis of Finfgeld-Connett .
The strength of this study is the two steps of the validation procedure. The achievement of credibility in the inductive approach to qualitative content analysis implies careful consideration of issues arising at every stage of the analytical process . In the present study the basic principles of latent content analysis were applied, which means that there was systematic coding into subthemes and then integration into a theme . The credibility of the inductive analysis was strengthened by means of comparing the subthemes and the theme with concepts from 44 qualitative studies in the previous metasynthesis . The findings added more attributes to the previous model, and a significant contribution is the insight that social support is provided mainly by non-professionals.