In the study, we conducted a comprehensive assessment of the online education among international medical and nursing students from LMICs and their teachers during the COVID-19 crisis, and we found that: (i) most teachers were satisfied with the online education experiences, whereas most students were dissatisfied; (ii) teachers’ professional title, students’ year of study, continent of origin and location of current residence significantly affected the online education satisfaction; (iii) the most influential facilitating factor to online education for students was a well-accomplished course assignment while that it was good administration of the online courses for teachers; (iv) the most influential barrier to online education for students was the severity of the COVID-19 situation while it was the sense of distance for teachers.
Currently, around 75% of the international students are staying outside China during the pandemic, and this percentage tends to continue rising as international students still keep leaving China; meanwhile, it is unpredictable when the out-China students could return to the campus . Therefore, it seems that the large number of out-China students will study and even graduate remotely over a longer period of time. In this aspect, our study provides important references for government and medical schools in China to improve their online health sciences education for international students, whose training qualities will affect the healthcare delivery in their future practice locations around the world.
Effectiveness of online education
The effectiveness of online learning in imparting a health sciences curriculum has been supported by some empirical evidence, exemplified by medical and nursing students’ promising outcomes in tests [12, 26] as well as their positive perceptions on the acquisition of knowledge [27, 28] and skills [29, 30]. Several recent studies also reported a high overall satisfaction rate for the online education during the COVID-19 crisis among Chinese (80.29%) and Indian (97.14%) students and teachers at medical schools [14, 31]; however, a study from Jordan reported a low satisfaction rate (26.77%) with the distance e-learning amid the pandemic among medical students in clinical years . In this study, we found a comparatively low satisfaction rate in international students and a medium satisfaction rate in their teachers, whose online education experiences were significantly influenced by various factors.
Factors affecting online education
Factors related to the crisis
The crisis was noted to significantly reduce both students’ and teachers’ education satisfaction. Although the pandemic intensely affected the students staying outside China, it did not affect the students staying inside China, which might be explained by the different pandemic circumstances in different regions.
During our survey period, the data of the existing infected cases in China had declined remarkably, while in many other parts of the world it was on the rise . At the time of the survey, 153 (66.5%) of the students in our study were staying overseas, among whom, 102 (44.3%) were in India, where the newly diagnosed cases were generally above 1000 each day . It is therefore understandable that the factors related to the COVID-19 pandemic—the epidemiological data (Sa-01), the lockdown (Sa-02), future uncertainties (Sa-05) and the economic issues (Sa-06) exerted a detrimental impact on online learning for students outside China, while these factors did not affect students staying in China. As the pandemic in different countries still fluctuates, medical schools in China should keep an eye on the pandemic in students’ current place of residence and pay extra attention to those faced with more serious situations.
On the other side, the teachers, who were also staying in China and thus supposed to be free from the influence of the crisis, turned out to be greatly influenced. The reasons might be two fold. First, 46.3% of the teachers in our study teach clinical subjects, who work in the clinical setting and were exposed to the high-risk environment during the COVID-19 crisis, suffering from stresses such as long working hours, risk of infection, physical fatigue, and so on , which presented challenges to their online teaching conditions. Second, a massive number of courses had been transitioned from offline to online due to the crisis. As for the 74.7% of the teachers without previous online teaching experience, they were forced to bear huge pressures according to the wholly online requirement; as for rest of the experienced teachers, they could hardly fulfil their expectations with online teaching as a suboptimal mode with such short notice, considering that the previously built online courses were well prepared with plenty of time.
Among the crisis-related factors, the current learning environment (Sa-03) and the current teaching environment (Ta-03) were found to promote the education experiences for students outside China and teachers inside China, who share something in common—they are studying or teaching at a familiar and relaxing environment, surrounded by their family or friends. According to Zhang et al. , a comfortable environment and support from close ones can help overcome negative emotions during the pandemic, so students and teachers in more familiar surroundings are more likely to cope with adverse feelings better and thus enjoy their online education more. This inference is reinforced by the finding in our study that the learning environment was not a promoter for students inside China, who are far away from home and familial relationships. This fact implies that in-China students’ emotional stresses, such as homesickness and loneliness, which might become more serious as the separation with family prolongs, need to be pacified with the necessary timely psychological support.
Factors related to learners and instructors
In this study, the international students’ learning satisfaction was closely associated with the influence from the teachers rather than themselves. Interestingly, the teachers’ education satisfaction was, in fact, closely associated with the influence from the students.
The results showed that factors related to the attitude and engagement of learners (self-discipline, cooperation, learning motivation, time regulation, assignment completion, access frequency to the internet, participation in discussions, message postings, lesson reviewing, and resource usages) and instructors (attention to the students, interaction with students, resource preparation, availability for students, passion for teaching) significantly affected online education. These findings have also been emphasised in the literature as important aspects influencing the effectiveness of online learning [10, 23, 34]. When taking a closer look, we found that many of the above-mentioned learning attitude and engagement factors affected only students outside China but not students inside China. This could be attributed to the fact that many students staying overseas largely depend on the asynchronised mode of online learning due to the time change or network issues, which, therefore, demands higher autonomy and initiative. However, as there is a change regarding the availability of some online live streaming platforms and online chatting tools in some international students’ countries of origin during the past year, there has been a massive decline in the proportion of synchronised classes while the asynchronised mode now serves as the mainstream to deliver online courses to and conduct real-time interactions with students to facilitate the accessibility of the coursework. Predictively, students’ learning attitude is likely to have a stronger impact on their online learning outcome, so administrators and teachers are encouraged to make every effort to maintain students’ engagement.
Familiarity of technological skills was not found to be an influential factor for both students and teachers, manifested in their rating results for items Sb-03 and Tb-03, which is in line with Bao’s viewpoint  that learning attitudes outweigh technology skills regarding online learning. Bernardo et al.  also stresses that students’ quick adaptation in using the Internet for academic studies can compensate for their unfamiliarity with the web technologies at the beginning. However, some researchers conclude a two-way causal relationship between technological skills and students’ engagement in online learning, emphasising that the mastery of the former strengthens the latter , and the latter facilitates the development of the former .
Factors related to courses
Our results showed that technical issues, such as network conditions (Sd-03) and facilities used (Sd-05), significantly affected students’ dissatisfaction of online learning. This finding is in agreement with studies in India , Malaysia , Ghana  and South Africa . All the students in our study were learning online in LMICs. As documented by Frehywot et al. , the implementation of e-learning among health sciences students in the resource-constrained LMICs is usually technically challenged, and the main problems include slow speed of accessing and downloading from the Internet, poor quality images/sounds, limited electronic facilities and frequent electrical power failures. To ameliorate technical disturbance on e-learning in less privileged settings, scholars propose the application of approaches requiring less bandwidth, such as a hybrid teaching method or a digital library independent of the Internet . During the past year, XZMU has adopted several measures to optimise the online education for the international students in technically challenged LMICs. For example, to reduce the negative effect of poor Internet connectivity and prohibitive data cost, teachers are recommended to upload short videos instead of longer ones. Furthermore, the online assessment methods have also been adjusted from closed-end questions at fixed examination hours to open-ended questions, clinical case analyses or essays within a more flexible time frame to ensure fairness in case some students suffered from issues related to the network or electronic power.
Additionally, the absence of experimental/practical classes was considered as an important inhibiting factor for online medical and nursing education by both students and teachers. Our results also showed that students in their clinical years were significantly more dissatisfied than those in their basic years, which implies that the unavailability of the clinical experience possibly produces a more adverse effect on theory learning than the inability to undertake experiments does. In fact, thanks to digital technology, experimental operations traditionally learned in laboratories and clinical skills traditionally acquired in hospitals are presently allowed for online learning. For example, some medical schools in Australia and the UK have already replaced dissection with e-textbooks and online resources in anatomy teaching . Moreover, during the COVID-19 pandemic, an American institution utilised telehealth clinics for surgical residents to maintain their clinical exposure, enabling the trainees to partake in the whole process electronically, such as discussing with the attending surgeon over the phone after gathering the patient’ medical record, videoconferencing with the medical team and the patient to formulate the treatment plan . Although it seems feasible to perform experiments and clinical practice online, which provides an example of how to cope with the current policy of restricting gatherings, it is argued that face-to-face contact and interactions with classmates as well as instructors are preferred for experimental hours  and the hands-on clinical operative experiences and direct patient care are indispensable . Therefore, there is an urgent need for universities in China to cope with these challenges creatively by establishing collaborations not only internationally but also domestically. In a recent national conference pertaining to international medical education, proposals have been put forward that medical schools in China are recommended to collaborate collectively to connect with overseas medical schools and hospitals especially those situated in the IMSs’ and INSs’ countries of origin, so as to provide alternative experiences locally for the experimental classes and clinical practice they are missing .
Expectation of online education
Despite the fact that online learning is well accepted as a sound and enjoyable method, health sciences students hardly see it as a replacement for offline learning . Instead, e-learning is more regarded as a supplement to support traditional didactic teaching  or a component of blended learning . In our study, we found that students’ acceptance of solely online learning during the pandemic was low, but nearly half of the students expressed interest in online learning as at least part of the future education style. Additionally, nearly two-thirds of the teachers (64.2%) voted for online education for their future teaching. The future preference for online/blended learning is even higher among medical students or teachers from Jordan (80.7%) and Saudi Arabia (88.0%) [13, 15]. A year has passed since our survey and the learning trajectories for in-China students have basically returned to normal with all the face-to-face experimental classes and clinical practice fully resumed. Meanwhile, not surprisingly, online learning has been retained by many medical schools as an important component to supply offline teaching of the theoretical knowledge, which mirrors the expectations of students and teachers from our survey.
Despite the massive disruptions the pandemic has brought to the medical and nursing education for international students, this technological revolution also opens the door to a new world. Not only online learning, but online assessment and online graduation are also born at this moment, which helps medical schools speed up the process of internationalisation and explore worldwide distance education possibilities.