14 TOTAL EDUCATIONAL COSTS OF AN INTEGRATED NURSING CURRICULUM 1

Innovative changes in undergraduate Nursing programs have brought about new methodologies and the need for cost evaluation. This study aims to develop a model for cost estimation, and to estimate educational costs of an integrated Nursing curriculum at a public university. This is a case study conducted in stages: model development, data collection, analysis and interpretation. The cost-construction model consisted of six steps: data collection; educational and support activity costs; four-year course educational costs; educational support costs; joint product costs and total educational costs. Findings showed a total educational cost per student/year US$ 3,788.82. Course team faculty included 97 members. The cost analysis in faculty contact hours is the most appropriate cost unit as it most consistently reflects faculty time devoted to teaching. The knowledge about educational costs provided information that may be useful for a different approach to the integrated curriculum management, with a view to putting its educational objectives in practice.

Innovative changes in undergraduate Nursing programs have brought about new methodologies and the need for cost evaluation.This study aims to develop a model for cost estimation, and to estimate educational costs of an integrated Nursing curriculum at a public university.This is a case study conducted in stages: model development, data collection, analysis and interpretation.The cost-construction model consisted of six steps: data collection; educational and support activity costs; four-year course educational costs; educational support costs; joint product costs and total educational costs.Findings showed a total educational cost per student/year US$ 3,788.82.Course team faculty included 97 members.The cost analysis in faculty contact hours is the most appropriate cost unit as it most consistently reflects faculty time devoted to teaching.The knowledge about educational costs provided information that may be useful for a different approach to the integrated curriculum management, with a view to putting its educational objectives in practice.DESCRIPTORS: curriculum; costs and cost analysis; education higher; education; nursing; faculty nursing; undergraduate course
There is international research on nursing education costs (3)(4)(5)(6)(7) , but no studies have been conducted on nursing curriculum innovations in Brazil.

Background of curriculum changes in Brazil
Brazilian Nursing education was officially initiated by Decree nº 16300/23 in Rio de Janeiro.
There were some curriculum changes in Nursing education in Brazil in 1923, 1949, 1962, and 1972 (8) .
Afterwards, from 1970 to 1985 there were great professional advances, backed by public health policies from the World Health Organization (WHO) and the Pan-American Health Organization (PAHO) (9) .
In the 1980's, public health policies incorporated some concepts into education, such as equity, integrality and universality.At that time, a discussion started about the need to reform the 1972 curriculum, which was primarily hospital-centered (10)   .This curriculum no longer met the demands of nursing education, and there was also a need for changes concerning primary health care.
The Brazilian Nursing Association had set out a professional movement proposing a new curriculum approach, which was sanctioned by government Decree nº 1721/94.Education offered an opportunity for change while developing students' critical awareness and social commitment (11) .
A major curriculum approach that influenced education theory and Brazilian educators was social reconstruction, (12) which adopts political emancipatory values to face social concerns and change reality.
At this same university, the Nursing program underwent its sixth curriculum change in 2000, to develop a so-called integrated curriculum.The university faculty members chose to "go beyond the structural curriculum reform, and to know and change educational practice" (14) .This proposal, based on critical-social education concepts, broke with traditional teaching models (15) and supported problem-

OBJECTIVES
The objective of the present study was to develop a cost estimation model, and to estimate the

METHODS
Prospective case study, carried out to estimate educational costs of a Nursing program.
A case study is the most comprehensive method in terms of data collection.Data can be collected from documentary analysis, interviews, personal reports and spontaneous observations, among others (16) .
The study comprised the following steps: cost model development, data collection, analysis and interpretation.
Some definitions were established for a better understanding of the concepts applied to this study, as follows: Educator contact hour (ECH) -one ECH is a 50-minute class when the educator was physically present, in direct contact with students, in clinical or theoretical teaching activities.
Educational costs -academic costs related to the teaching program and its support (faculty time devoted to directly related teaching activities).

Educational support costs (ESC) -faculty activity costs essential to education and teaching-learning competencies (administrative activities).
Joint product costs (JPC) -total joint or shared activity costs related to the teaching hospital.
Direct costs -costs directly related to the teaching program; the faculty working hours devoted to teaching in educator contact hours.

Cost-construction model
The cost model constructed for data collection and estimation of the Nursing Program educational costs was based on the Cost Analysis and Construction Program (PCAC) (17) .Teaching costs, joint product costs and total educational cost parameters and definitions (1) were also included.The educational program costs are constructed by curriculum analysis and calculating the ECH * required to maintain it (1) .
The total educational cost estimate model for a Nursing program ** consists of six steps, as described below.
Data collection and analysis

RESULTS AND DISCUSSION
The results and discussion are presented together.Relevant aspects regarding estimated costs of the integrated curriculum are discussed here.PCAC (17) was developed for cost analysis of Medicine programs in Canada.It was based on a costconstruction model used by the US Institute of Medicine (IOM) in 1974 to estimate eight health education programs, including Nursing.This study was criticized because of its small sample size, representative of less than 3% of US Nursing schools (18) .
Studies on the nursing area (3)(4)(5)(6)(7) have failed to provide useful cost models and, thus, a new model had to be developed and adjusted for the present research.
In the PCAC (17) and the cost model presented here, direct costs related to undergraduate programs were collected in ECHs.
Educational program cost evaluation is complex (5) .Researchers often do not make careful cost comparisons between countries and institutions in the same country (19) .Comparisons can be made only if the same methods were applied in the cost analyses (19) .Besides, particularities of each institution Four-year educational costs Teaching costs were described for the Medical area (1) and, here, they are called educational costs related and limited to the undergraduate program analyzed.
The four-year educational costs are presented in Table 1. for classroom activities in the 1 st and 2 nd years and between 1:10 and 1:15 for clinical contact (6) .
Costs and ECHs gradually increased in the 2 nd and 3 rd years because of decreasing educator/ student ratios during clinical activities, 1:5 and 1:6 on average, due to the increasing complexity of activities performed by students in clinical sites.The average educator/student ratio in clinical sites reported in nursing education studies was 1:6 (7) in the US and 1:11 (6) in Central Africa.
Nursing program costs increase due to the need for a low educator/student ratio, as more faculty members are needed for clinical supervising.
Educator/student ratio was the specific variable that affected Nursing education costs in the IOM study (4) .It is also known that faculty jobs account for the highest costs in colleges (3)   A limitation of the present study was that costs related to intangible activities were left unmeasured (20) .
These costs cannot be accurately measured and are associated to daily faculty activities such as course preparation, refresher courses, evaluations of course assignments, faculty meetings among others (20) .
Further studies are needed to assess intangible costs.

CONCLUSION
When it was decided to estimate integrated curriculum costs, the authors' main concern was to find an adjustable cost estimate method.The PCAC (17) described and applied in Medical education, proved to be a feasible method.
Another concern was that cost estimates could be used for diagnosis and evaluation of the implementation of innovative curriculum approaches.Costs should be one of the many components assessed while evaluating the feasibility of a new approach.
Moreover, the constructed model, so-called Total Educational Cost Estimate Model for a Nursing Program (MECEE) (20) , provided input on faculty It is suggested that MECEE (20) should be the standard model, as it has proved to be consistent and practical for estimating educational costs of Nursing and other health-related programs.The approach studied took into consideration educational program characteristics and proved to be complete and systematic.Further studies should be conducted to explore the relevance and efficacy of this cost model.
based principles.One of its goals was integration of faculty members and multidisciplinary work to improve students' learning.The model allows students to break their basic knowledge as they acquire the new content.This process requires time for faculty team to prepare learning activities, as well as extra time for faculty-student contact, so that the learning process can take place.Undergraduate health schools undergoing these curriculum changes also met some challenges, such as incorporating new methodologies and evaluation models, integrating basic and clinical science faculty and contents and interdisciplinary practices within and outside school.Nursing graduates will have to respond to the challenges they will encounter in their real jobs.New educational practices entail process changes and, probably, different costs.Cost estimation is a factor to be included in the analysis of changes already in place, but it cannot be considered individually.In addition to costs, the analysis of results and impact of curriculum changes should include other factors.Health education managers need to know the actual operating costs of these programs.The Brazilian Ministries of Health and Education, as well as Curriculum Guidelines for Health programs, have undergone a change process and further curriculum reform requires an in-depth analysis of educational costs.
Total educational costs of an integrated…Bobroff MCC, Gordan PA, Garanhani ML educational costs of an integrated Nursing program at a public university in the state of Paraná, Brazil.
st step -Data collection from records and interviews: data were collected by the main investigator in 2005, 2006 and beginning of 2007.Cost analysis was made in reais and American dollars *** .a. Documentary analysis: university records relevant to identify cost areas were analyzed before constructing the model and during data collection and analysis.b.Interviews: A structured questionnaire was developed by the main investigator for carrying out semi-structured interviews with 52 individuals **** about their ECHs.The number of meetings for the i n t e r v i e w s w a s g u i d e d b y t h e l e n g t h a n d complexity of each course.Data validation was performed by showing them to at least one faculty m e m b e r o f e a c h c o u r s e a n d E C H d a t a w e r e showed to the interviewed faculty coordinators for final validation. 2 nd step -Educational costs by year and support activity costs: ECHs of each year were calculated according to the faculty members' salaries in the program and supporting and basic activity costs, which together totaled direct and indirect costs and the total month/year student costs.3 rd step -Four-year educational costs: based on the costs obtained for each year in the 2 nd step, the total for a four-year program was calculated by summing them.4 th step -Educational support costs (ESC): direct costs for preparation and management of educational activities by the faculty member (headship, commission and coordination of each of t h e 1 6 t e a c h i n g c o u r s e s a n d u n d e r g r a d u a t e teaching projects).
and teaching program should be taken into consideration to allow for a comparison.The study results could not be compared with those of other studies, as no studies with the same cost methodology were found in the literature.Other authors' comments and research results were included to support the study results.* Data were collected from the Planning and Administrative Developing Management of the Dean's Office at the university and proportionally weighted: 1.0 for Medicine, 0.75 for Nursing, 0.5 for Pharmacy and 0.5 for Physical Therapy.
course hours distribution, ECHs carried out throughout the school year, and different faculty and departments' involvement in the program's activities.Besides gaining knowledge on undergraduate costs, the model has also provided some evidence about the performance of the integrated curriculum.-The two departments most involved in faculty activities in the Nursing program were the Nursing and Community Health Departments.-The Nursing Department focused on student contact activities in the undergraduate program, which increased linearly from the 1 st to 4 th year.But the same was not seen in other areas, such as Community Health and Basic Sciences.-There has been a remarkably different involvement between faculty from Nursing and Community Health and from basic areas, raising a concern about the integration between the various areas of knowledge.It is notable that, despite its relevance for teaching, university hospital joint product costs substantially increased Nursing undergraduate education costs.The findings of the present study may help the program faculty to discuss and review criteria for better distribution of course hours and ECH, and more adequate and balanced involvement of specialists from different areas in the program courses.Knowledge on undergraduate educational costs can contribute to improve the management of an integrated curriculum through a different approach.

Table 1 -
Distribution of educator contact hour, total cost by year (R$ and US$) Legend: C/H -course hours per year ECHs -educator contact hoursTable1shows that there has been a linear increase in ECHs and costs from the 1 st to the 4 th years.A lower number of ECHs in the 1 st year can be explained by the fact that students were first approaching real professional activities, at a 1:10, 1:20 and 1:30 educator/student ratio during clinical practices.Higher ratios were reported in a study conducted in Central Africa, where they found 1:60

Table 2 -
Distribution of mean ECHs and related standard deviation Data collected from the Planning and Administrative Developing Management of the Dean's Office at the university showed a Nursing program cost of US$ 5,003.59 in 2003 and US$ 5,331.76 in 2004. *