Diabetes Mellitus (DM) is the new epidemic in the world with 246 million people suffering from the disease at the moment and a projected increase to 380 million in 2025 (IDF, 2007b:36). The developing countries are the most vulnerable. Statistics state that SA and Egypt have the most diabetics on the continent. Globally, each year 3,8 million deaths are attributable to DM (IDF, 2007a). The Department of Health (DOH) and the Cacadu District Municipality (Eastern Cape) are serving a population of 102 721 in the Kouga and Koukamma areas, which covers an area of 5 992 km², with health care. There are 22 clinics with 28 registered nurses for all the clinics and between 3 and 9 lay health workers (LHWs) per clinic. For the purpose of this research study, the persons suffering from DM (±3550) in this area were taken into consideration (Strydom, 2005). DM is a chronic disorder and therefore patients should be able to manage their disease pattern for the rest of their lives (Healthline, 2008, Mbanya, 2006:12). In order to achieve this, continuous and effective patient education by health care providers are necessary. This disease affects more and more people each passing day, because of the rapid westernisation of the South African population, leading to more people attending clinics in the public health sector (Bonnici, 2002:32). There are specific guidelines laid down by the Department of Health (DOH) pertaining to the control and management of DM. Guidelines include the early diagnosis, treatment and patient education regarding DM (Department of Health, 1997, [revised 2004]). Evidence from previous research studies showed that not all registered nurses are aware of these guidelines and most have not been educated regarding the utilisation of these guidelines (O’Brien, van Rooyen & Carlson, 2006:36-40). In the clinics, the health care givers are confronted with a number of difficulties, such as a lack of funds to enable them to order adequate equipment and medicine. Another problem is the migration of registered nurses out of the country thus; there is also a shortage of staff to operate these clinics (Mkhize, 2004). The organisational structure in the clinics does not function optimally and there is a lack of communication between provincial, district and clinic level. Due to the above-mentioned challenges there is also a lack of efficient auditing systems to ensure quality assurance. Furthermore, a knowledge deficit pertaining to DM and the management thereof in all the groups participating in this study, namely the registered nurses, the lay health workers (LHWs) and the diabetic patients was found. The empowerment process of the LHW is not explored fully and therefore not executed to its full potential. To be able to improve the management of DM in this region, it is important to know what the difficulties are that the health care givers as well as the patients experience in relation to this issue. This study therefore explored and described these difficulties. The research was based on a qualitative, quantitative, explorative, descriptive and contextual research design. Health care givers as well as diabetic patients attending clinics in the Cacadu region of the Eastern Cape have been requested to complete questionnaires pertaining to their knowledge of Diabetes Mellitus. The current organisational structure of the provincial department of health was explored and findings analysed using the activities of the management process (Muller, 2006:106). The SA Government is committed to combining the national human resource development strategy with the rapid upgrading of service delivery to all of the nation’s communities. Stemming from this undertaking, suitable members of the community are to be trained as LHWs. LHWs are to play an integral role in strengthening the abilities of the community to empower themselves to participate and take responsibility for their own health and wellness (Department of Health, 2001a:4). From the research, it was found that the above-mentioned national plan had been implemented, but is not functioning at optimum level due to several shortcomings/deficits. Proposed guidelines were therefore designed to address the shortcomings and fragmentation of the plan. As specific knowledge deficits in DM were identified during this research study, general educational guidelines were included for the registered nurses and the diabetic patients. The LHW was identified as an indispensable link in the chain of efficient health care and therefore, specific educational guidelines on DM were generated to prepare her for the role. With her knowledge, insight into DM and the management thereof and newly required skills in educating and supporting of the patient, she could be an asset in the road to optimum self-care for the diabetic patient.

In severely ill hospitalised patients with diabetes mellitus (type 1 and type 2) there is an increase in metabolic rate. Insulin requirements are increased and glycaemic control becomes more difficult to achieve. The insulin sliding-scale is a form of „top up‟ therapy used to supplement the patients existing hypoglycaemic medication. In 2002, research at Livingstone Hospital found that 14 different sliding scales were used in 38 patients (Du Plessis, 2002: 79). In 2006 the nurses and doctors working in the general medical wards at Livingstone Hospital indicated that they were willing to use a standardised insulin sliding scale protocol (Smith, 2006: 56). Thus the aim of this study was to assess whether a standardised insulin protocol can be effectively implemented. The objectives of the study were to: 1) assess insulin usage via insulin sliding scales prior to the implementation of the standardised insulin protocol; 2) implement the standardised insulin protocol; and 3) reassess insulin usage after the implementation of the standardised insulin protocol. As the study involved evaluating the use of insulin via the insulin sliding scale and the implemented insulin protocol, it occurred in four phases. The preliminary phase entailed obtaining ethical approval. The pre-intervention phase included data collection in the form of a nursing questionnaire and the auditing of patient medical records using a data collection tool. The intervention phase involved education sessions on the new insulin protocol for the nursing staff, and the implementation of a standardised insulin protocol, while the post-intervention phase comprised of post-intervention data collection, which included a nursing questionnaire, a prescribers questionnaire and the auditing of patient medical records using a data collection tool. The overall impression obtained from the comparison between the pre- and post-intervention nursing questionnaire was conflicting; in some aspects the educational intervention was successful in others not. Regardless the indication obtained was that the nursing staff require more in-service training on a more regular basis as a lack of knowledge regarding diabetes mellitus as a disease state may negatively affect patient outcomes. The overall response from the nursing staff towards the insulin protocol was positive. The prescribers‟ response to the insulin protocol was conflicted. The number of correct insulin sliding scale doses administered in the pre-intervention and post intervention phase improved by 5.25 percent. The number of incorrect insulin sliding scale doses administered during the pre- and post -intervention phase decreased by 5.25 percent. These results are positive and may be due to fewer sliding scales being prescribed in the post-intervention phase and the implemented insulin protocol. Only three (5.55%; n=54) inpatients with Type 1 diabetes mellitus were placed on the implemented protocol that is, the basal bolus regime, and rarely were dose adjustments to their insulin made rendering the effectives of the protocol undesirable. Only four (7.40%; n=54) inpatients with Type 2 diabetes mellitus were placed on the implemented protocol that is, an intermediate- to long-acting insulin (Protophane®). However all four patients experienced immediate improvements in their fasting blood glucose levels. These results indicated that by adding an intermediate- to long-acting insulin (Protophane®) to the therapy of a patient with Type 2 diabetes mellitus fasting blood glucose levels decrease. This would improve patient outcomes and decrease the risk of related diabetic complications. These limited results may indicate a clinical inertia on the part of the prescribers. Unfortunately overall the educational intervention was not successful and the implementation of the protocol was not successful and did not yield the desired results.