Table 4.

The 4 key themes, related sub-themes and meaningful quotes

Theme	I	Meaningful quotations
1. Ways and Meanings of the BU’s collaborations	1.1 How and why to access the BU	So in certain circumstances, I asked myself: Which person is the most competent to help you with this specific question? And I autonomously identified her (the Head of BU)" (cod. 1.4). We certainly made the initial request, because we needed an opinion, a point of view different from ours. This, perhaps, is ethics: a different vision from ours. (C.15.10) The reasons that led us to contact the BU were: first, the fact that the bioethics unit exists. This is the main reason: it is not so common for a hospital to provide this resource (c.6)
	1.2 The BU’s role and activities	If we talk about the ethics training (…) it brought attention to topics that we usually lack some knowledge of (C 2.3) In my innermost thoughts, I thought (my choice) was right, but in that moment (…) I needed someone to rationalize all the choices and the path of care, someone who could support me (c.5.18). In the educational activity, we discussed specific cases, (…) which created a bit of disagreement within the care team regarding the decisions to be taken on palliative sedation (…), and this made it clear to me and to the nursing coordinator that there was a need to increase the training activity on this topic (c.11.1.5). I believe that the BU’s aim is very clear, which is to give us more confidence and provide ethical support, not only methodological, towards choices that have to made…choices that are often less clinical than those taken elsewhere. (We work in a unit where) non-clinical choices have equal dignity to clinical choices (C.16.3).
2. The role of the bioethicist and organizational aspects	2.1 Personal attitudes and specific competencies	The strongest point is the training in the field, namely the discussion of real cases together: then you understand the whole theoretical part (c.10) The first times I changed my point of view on the case, being less focused on ‘doing’, it was a shock to me too. Then… knowing that no one judges you… the bioethicist is the right figure for this type of support. (C.18.20) In our setting there are, as well as perhaps in other settings, cultural aspects that in my opinion it is important to be aware of, and from this point of view, having referents who specifically study these things, and have a background and the ability to follow the current ethics questions is fundamental for having feedback, also for the overall growth in the system of our department (c.11.41)
	2.2 Organizational aspects	If I have a symptom X, I do something to cure the symptom X, and I need to have the result immediately. On the contrary, considering the care path, I do something, and I will see the result after a long time, it is a path built in many steps. This is perhaps the difficulty of making the two facets interact with many other facets: I think this (ethics) is a facet of our work, but it doesn’t always fit in with the timing we are used to working with. (c.3.28) If there is only one person (the head of BU), you do not know who to refer to. Probably there is a limit (…) in the sense of having only one contact person. (c.11.45) I didn’t even know (the BU) existed, (…) I could never have made the contact if I hadn’t found out from someone else. (…) knowing that it exists is important, to spread this opportunity. (c.5.43) (There are) organizational (limitations) but also regarding cultural aspect of both executives and us as professionals: because we are inside this logic of doing and doing, and you are not allowed to think about the ethical aspect of doing…(reflecting on it) is experienced as a luxury (c.2.21)
3. Impact on the HPs’ attitudes	3.1 A deeper way of thinking	It is very important to have other ‘’two eyes’’ trained on this type of comparison. It allows you to refine, to mature, to give a little more depth to your assessments, to your orientations." (c.1.10) The possibility of drawing on a professional who is not strictly clinical but also has a wider philosophical tradition, which is more extended compared to the questions we are usually accustomed to thinking, but which in real life concern the daily choices of clinicians and patients (c.6) In the end, (the Head of BU) not only helps you to deal with the question that arose, but also helps to strengthen the group and therefore in my opinion it is a doubly positive result. (c.13.22) Then there were also situations in which we realized that the problem was not ethical but was more relational or organizational. But (the ethics intervention) was useful anyway, because we also understood what kind of problem it is: since we work within complexity, it helps a lot. (c.14.10)
	3.2. Identifying new questions in clinical practice	I think there’s been a positive impact, in the sense that we, as clinicians, are far ahead clinically. (…) She (the head of BU) suggested that we go step by step, take small steps, set small goals and see on the other side how the parents respond. It is not easy for a parent to become aware of the child’s illness. In this way, instead, they arrive prepared, but we must not do everything immediately. (C.18.9) Sometimes we clash also, we clash in the sense of a comparison among us, among our different points of view, and in my opinion the tools that are offered to us (by the BU) help the care team to be a little more at peace. (c.14.20) (There has been) an improvement in the relationship with patients. (…) While before, the meeting with the patients took place on two slightly separate levels, we at the top and patients at the bottom, I saw this distance was reduced. And so more and more professionals are trying to put understanding at the core of the health care relationship, even when things aren’t really great. (c.15.33)
4. Further needs		I think that considering all this no longer in an informal way but in a planned, structured way can be absolutely useful." (1.16) More structured, because when we need (the BU intervention) the situation is probably already too far advanced. If I had a consistent presence, (…) she makes me aware in time that there is a need for something more, to implement a care pathway where I usually arrive too late. (c.3.23) So sometimes I asked myself: Why not bring this way of training to other departments? Because an oncologic patient is in all departments, because the “questions of meaning” arise in all the departments (…) (c.13.38) What I think and hope is that having a system within the health care facility (dealing with ethical aspects of care) will push (…) all the departments to provide health care professionals with an ethical basis, because ethics is the basis of the profession and still too many nurses do not perceive that (…) goes beyond in so many ways (C.16.35) So I hope it really becomes a way to bring it to everyone, because everyone has ethical doubts but sometimes they don’t know them and so the crises arise. (…) I think this year has brought it to light a lot (due to the COVID-19 pandemic), (…) there have been many ethical choices and they often have not been perceived, and this perhaps has aggravated a crisis that was already serious from a clinical point of view. But the clinical practice raises questions that are easier to solve than the ethical ones, and so I think it’s right to care for the HPs from this point of view, otherwise we would have HPs who are much more sterile and much more unhappy in their doubts. (c.16.36).