Society For The Study Of Addiction

QMJC October 2020 – The perceived impact of legalized cannabis on nursing workload in adult and pediatric emergency department visits: A qualitative exploratory study

Article: Lisa A. Wolf, Cynde Perhats, Paul R. Clark, Warren D. Frankenberger, and Michael D. Moon. 2019. The perceived impact of legalized cannabis on nursing workload in adult and pediatric emergency department visits: A qualitative exploratory study. Public Health Nursing, 37:5–15.


Toronto reading group – October meeting: Carol Strike; Katherine Rudzinski; Andrea Bowra; David Kryszajtys; Cathy Long; Sarah Switzer; Tara Marie Watson; Jessica Xavier (Dalla Lana School of Public Health, University of Toronto)

Meeting summary:

In the final meeting of our journal club on October 2020, we reviewed Wolf et al.’ 2019 paper, The perceived impact of legalized cannabis on nursing workload in adult and pediatric emergency department visits: A qualitative exploratory study. We picked this article because of its use of situational analysis but also because of its focus on a novel aspect of the impact of legalization. The authors explored emergency nurses’ perceptions of the impact of cannabis legalization on their workload related to emergency department (ED) presentations resulting from cannabis use/misuse. Two focus groups were conducted at a conference with n=24 nurses who worked in US emergency departments, in states were recreational cannabis is legal or bordering states, providing direct care to patients. Situational analysis was used to analyze data. Wolf et al. found that after the legalization of recreational cannabis nurses experienced an increase in patients presenting to emergency departments with cyclical vomiting syndromes, more difficulty in managing associated behaviours and repeat ED visits. Some nurses spoke about encountering increased cases of unintentional intoxication in both pediatric and geriatric populations. Nurses also reported an unexpected displacement of local homeless populations by young “cannabis tourists” from states bordering those where recreational use was legal. The authors note their findings support to the need to standardize the formulation, dosing, and labeling of cannabis products to protect public health and safety while planning for cannabis legalization. Educational initiatives for consumers, health care providers, and social service agencies were also identified as crucial.

Journal club members liked that Wolf et al. focused on an area of cannabis legalization research that is not often examined. The paper allowed us to learn about the perspectives of ED nurses, their view of who is presenting to emergency departments with cannabis specific issues, and what that means for their day-to-day work experiences. We thought it was very valuable to have a qualitative study of nurses’ viewpoints on cannabis related issues in the emergency department to complement, the existing literature on cannabis legalization. This paper was especially interesting for the journal club to discuss as it challenged some of our positions on cannabis legalization.

Many journal club members were new to, but very interested in, using Clarke’s situational analysis. This approach uses a grounded theory methodology to identify social worlds/arenas and describe/represent their complexity through three different types of analytic maps: situational maps, social worlds/arenas maps, and positional maps. In reviewing Wolf et al.’s work we discussed the potential of situational analysis to explore complexities and inter-relationships in contemporary substance use research. The authors focus on situational maps and present a detailed synthesized map of the key human, nonhuman, and discursive elements, constructs, discourses, and issues/debates central to their situation of inquiry. We used it to discuss how such elements (e.g., policies, discourses around use, etc.) – especially the higher level ones – interact/connect with one another to impact ED presentations and nurses’ perceptions of changes to their workload. Clarke encourages researchers to continually move between messy and ordered maps, making connections between elements and examining issues from multiple perspectives. While perhaps not labelling our processes as situation maps, we all recognized these drawings in our work as we seek to synthesize our data. It would have been great to see some of the messy maps, to better understand the process of transitioning from messy into synthesized maps. We would also be interested to see how the situational maps created by the authors might evolve with more focus groups and perhaps over time as nurses’ experience and adapt to new workloads in legalized environments.

Unlike quantitative research methods, the qualitative methods used allowed the authors to highlight the areas of silence- identifying actors and elements that are not raised directly but that have an effect on the overall issue. Wolf et al. recognize implicated silent actors (e.g., research actors, dispensary owners, policy actors). We were intrigued and wanted to hear more about what links the authors saw between these actors and some of the policy recommendations around education, better labeling, etc., as well as how these elements may influence nurses’ perceptions. For instance, the authors noted that the frequent use of high THC concentrated products can lead to cyclic vomiting syndrome” (p.6), and we wondered how issues of food handling with respect to edibles (i.e., problems with salmonella and botulism) may also add to the presentation of such symptoms in ED and necessitate legislation on how these products are produced/handled.

Journal club members were eager to discuss the topic of non-human materials/elements because it is such an integral part of what we all do as researchers of substances and the people who use them. The authors’ focus on foundational situational analysis texts yet we wondered what insights Clarke’s newer work, which is directed more explicitly to the role of non-human actors, might bring? For instance what if we started this analysis by examining the role of gummies? What kind of directions might this lead us in?

The journal club saw the potential in recruiting participants through a National Conference, as Wolf et al. did, since some of us have used similar methods in our own research. This recruitment strategy coupled with purposive sampling is efficient, providing researchers with a dedicated pool to recruit knowledgeable practitioners working in different settings (a captive audience). We appreciated that Wolf et al. gave us direct insight into their focus group guide questions as this provided a level of transparency to the qualitative process. Sharing these questions also helped us to recognize the value of using focus groups rather than one-on-one interviews as the method of data collection. Since the study included nurses from EDs across several states (i.e., California, Colorado, Massachusetts, New York, Nevada, and Utah), participants could compare/contrast experiences of workloads across states within each focus group.

One of the key strengths of this paper is that Wolf et al. analyze factors outside of the setting that contributed to the increased workload in the emergency department. Specifically, the authors considered how legalization and larger policy structures affect how people understand the cannabis products they are using, how these products are produced, and how they are sold. They then examined how this may impact nurses’ workload. This speaks to the value of the situational analysis approach in allowing the authors to analyze and understand the complexity of these connections. This led the authors to discuss the need for policy efforts around standardizing the formulation, dosing, and labeling of cannabis products. Future mixed methods research could examine hospital data regarding prevalence of ED presentations and compare/contrast this with what nurses’ are experiencing with respect to their workload.

Additional reading:

  • Clarke, A. E. (2003). Situational analyses: Grounded theory mapping after the postmodern turn. Symbolic Interaction, 26(4), 553–576.
  • Clarke, A. E. (2005). Situational analysis: Grounded theory after the postmodern turn. Thousand Oaks, CA: Sage.
  • Clarke AE, Friese C, Washburn R. (2018). Situational analysis: grounded theory after the interpretive turn. Thousand Oaks, CA: Sage.
  • Mathar T. (2008). Making a Mess with Situational Analysis? Review Essay: Adele Clarke (2005). Situational Analysis—Grounded Theory After the Postmodern Turn. Forum Qualitative Sozialforschung/ Forum: Qualitative Social Research, 9(2), Art. 4,
  • Fraser S, valentine k, Ekendahl M. Drugs, brains and other subalterns: Public debate and the new materialist politics of addiction. Body & Society 2018;24:58-86.