pone.0358880.t001 - <p> </p>

Data were analysed using Context-Mechanism-Outcome (CMO) configurations and linked to middle-range theories.</p> <p>Results</p><p>Three programme theories emerged: (1) Confident decision-making, where certainty, conversational aids, ethical reasoning, and outreach worker prompts influenced checklist use; (2) Trusting relationships, shaped by OWs’ approachability, situational awareness, and mutual respect; and (3) Perceived value, driven by altruism, narrative feedback, and perceived reductions in ED visits.

Relational coordination theory explained how shared goals, knowledge, and respect – reinforced by timely, accurate communication – enabled coordinated action. OW presence and recovery discussions were critical to foster confident and appropriate referrals among ED clinicians.</p> <p>Conclusions</p><p>The Trigger Checklist can support timely outreach potentially reducing drug-related harm in rural ED settings, but its success depends on relational dynamics, perceived value, and organisational integration.

To avoid checklist fatigue or tokenistic use, it should be embedded with the support of OWs who foster trust. These relationships will enhance use of the checklist as a meaningful intervention within complex care systems.</p></div>