Barriers and facilitators to online medical and nursing education during the COVID-19 pandemic: perspectives from international students from low- and middle-income countries and their teaching staff

Background The COVID-19 pandemic posed a huge challenge to the education systems worldwide, forcing many countries to provisionally close educational institutions and deliver courses fully online. The aim of this study was to explore the quality of the online education in China for international medical and nursing students from low- and middle-income countries (LMICs) as well as the factors that influenced their satisfaction with online education during the COVID-19 pandemic. Methods Questionnaires were developed and administered to 316 international medical and nursing students and 120 teachers at a university in China. The Chi-square test was used to detect the influence of participants’ personal characteristics on their satisfaction with online education. The Kruskal–Wallis rank-sum test was employed to identify the negative and positive factors influencing the online education satisfaction. A binary logistic regression model was performed for multiple-factor analysis to determine the association of the different categories of influential factors—crisis-, learner-, instructor-, and course-related categories, with the online education satisfaction. Results Overall, 230 students (response rate 72.8%) and 95 teachers (response rate 79.2%) completed the survey. It was found that 36.5% of students and 61.1% of teachers were satisfied with the online education. Teachers’ professional title, students’ year of study, continent of origin and location of current residence significantly influenced the online education satisfaction. The most influential barrier for students was the severity of the COVID-19 situation and for teachers it was the sense of distance. The most influential facilitating factor for students was a well-accomplished course assignment and for teachers it was the successful administration of the online courses. Conclusions Several key factors have been identified that affected the attitudes of international health science students from LMICs and their teachers towards online education in China during the COVID-19 pandemic. To improve the online education outcome, medical schools are advised to promote the facilitating factors and cope with the barriers, by providing support for students and teaching faculties to deal with the anxiety caused by the pandemic, caring for the state of mind of in-China students away from home, maintaining the engagement of out-China students studying from afar and enhancing collaborations with overseas institutions to create practice opportunities at students’ local places.


Background
The coronavirus disease 2019 (COVID-19) pandemic undoubtedly posed a huge challenge to the education systems worldwide, disrupting the normal teaching and learning trajectories [1]. As per UNESCO [2], over 100 countries had provisionally closed their educational institutions nationwide to contain the spread of COVID-19, and some countries had implemented localised school closures in large regions.
The COVID-19 virus broke out during students' winter vacation in China, and thus the coming spring semester faced the risk of suspension due to the national policy of temporary school closures. To address students' learning needs, the Chinese authorities responded by advising the education institutions at different learning levels to initiate fully online education starting from February, 2020 [3,4]. At present, there are more than 68,000 international students studying medicine and nursing in about 100 of China's institutions, mainly from low-and middle-income countries (LMICs) in Asia and Africa [5][6][7]. They have also been receiving online teaching during the COVID-19 crisis [8].
Although online education is well recognised and documented as a promising and effective mode for teaching undergraduate medical and nursing students [9,10], it was a different story to conduct fully online courses during the COVID-19 crisis, as the online courses' function and people's mental states can be very different from those during ordinary times [11]. More importantly, as for the international students who were currently learning distantly from their resources-limited homelands, the institutional readiness in technological and infrastructural supplies is not always present [12], which makes cross-national online education more challenging.
There have been several studies which assess online medical and nursing education amid the pandemic from Jordan [13], India [14], Saudi Arabia [15] and China [16], providing useful feedback on the online education for domestic students. In fact, as the circumstances began to stabilise, domestic students have started to progressively return to campus and face-to-face teaching has been gradually resumed. By comparison, for international students, online learning will remain as the main instructing modality for the foreseeable future [17], as many of them are experiencing difficulties returning to campus due to the international travel ban. Therefore, it is imperative and urgent to understand the landscape of online courses for this group of students, so as to monitor and improve the quality of the international courses. However, to the best of our knowledge, studies discussing the online education for international medical and nursing students from LMICs are unavailable.
Learner satisfaction and teacher satisfaction, which relate to their attitudes towards the education experiences and the achieved education outcomes [18,19], are among the "five quality pillars" in the quality framework of the Online Learning Consortium [20] and are thus highly predictive of the quality and outcome of the online courses [21]. Therefore, exploration of learners' and teachers' online education satisfaction and the influential factors can provide important guidance and reference for the improvement of the online education outcomes.
To understand the quality and influential factors of online health sciences education in China for international students during the COVID-19 pandemic, we surveyed a university in China (a provincial medical university representing the overwhelming majority of China's medical universities), with the aim to investigate the following aspects in our study: 1) attitudes of this university's international medical students (IMSs), international nursing students (INSs) and their teachers towards the online education experiences during the COVID-19 crisis, 2) personal characteristics affecting students' and teachers' online education satisfaction, 3) factors affecting students' and teachers' online education satisfaction, 4) differences in the influential factors for students staying inside China and those outside China, and 5) the influence of the COVID-19 crisis on online education.

Setting and participants
This questionnaire-based study was conducted between the 14th April and 23rd April, 2020, among the IMSs from 1st to 5th year, the INSs from 1st to 3rd year and their teachers at Xuzhou Medical University (XZMU), caring for the state of mind of in-China students away from home, maintaining the engagement of out-China students studying from afar and enhancing collaborations with overseas institutions to create practice opportunities at students' local places. Keywords: Assessment, COVID-19, International medical students, International nursing students, Low-and middleincome countries, Online learning, Satisfaction China. This university began to deliver online courses to its international students from the 24th of February, 2020, and up to the time of the surveys, students had been learning online for nearly 2 months. The online learning package tailored to the IMSs and INSs is blended with synchronised and asynchronised modes, delivering theoretical knowledge through a combination of real-time live lessons, recorded video lessons, required readings, compulsory assignments, and interactive activities (class discussions and communications about assignments), by means of live streaming platforms, video-uploading websites, emails, and social networking software. The learning goals and key points are provided alongside the course materials.
This study was approved by the Ethics Committee of Xuzhou Medical University.

Questionnaire design
There were two questionnaires, one for the international students and one for their teachers. The questionnaires were developed following 3 steps [22].
Step 1: This step was to collect information on the influential factors for the online education. Data were collected from international course teachers (individual views), international course directors (comprehensive views), international students (individual views) and international student monitors (comprehensive views). We sent emails to the course teachers and left messages in the student online-chatting class groups to kindly request their individual feedback on the factors that influenced their online education. Twenty-eight teachers and 34 students responded to our request by sending emails or leaving messages. Ten course directors were contacted by phone for a more comprehensive perspective, and notes were kept during the interview process. In addition, we invited 14 student monitors to participate in an online focus group discussion via the online chatting tool, where communications took place by typing words or sending voicemails. As student monitors were the coordinators between teachers and class members, they were more involved in and more familiar with each link during the whole online education process. During the focus group discussion, the student monitors were able to provide feedback from a more collective and general point of view through in-depth communications with us and between themselves. Responses were then summarised and transcribed into a Word document and analysed thematically.
Step 2: After an intensive literature review surrounding the topic of online education, more possible factors influencing online learning were added to the questionnaires to ensure the comprehensiveness [10,23]. The questions regarding the factors related to online education, based on the typology proposed by Zheng et al. [24], were then divided into learner-related questions, instructor-related questions, course-related questions, and additionally, crisis-related questions to fit for the purpose of our study. Then the structure of the questionnaires for students and teachers was settled and the draft version of the questionnaires was formulated.
Step 3: A panel of 4 experts in the field of health education and online education were invited to evaluate the content of the questionnaires with regard to aspects of the rationality of the items, overlapping or similar items, and the readability and interpretability of the items. The questionnaires were revised according to the experts' comments and finalised. Then we invited 2 students monitors and 2 class members to pilot-test the students' questionnaire, 2 course teachers and 2 course directors to pilot-test the teachers' questionnaire. They all provided very positive feedback for the design of the questionnaires.
The questionnaires for students and teachers had a similar format and both contained 3 sections. The first section collected the participants' basic information, such as age, gender and facilities used for online learning/teaching. The students' questionnaire also included grade, nationality and current residence, and the teachers' questionnaire included professional title, teaching experience, work type, place for conducting the online teaching, and teaching subject(s). The second section asked about the participants' perceptions of their online education experiences and expectations, such as the general satisfaction of the online education, acceptance of this new modality, preference of future education style, as well as the time and dedication spent on online learning/teaching. The third section included five-point Likert-scale questions about the factors influencing the participants' satisfaction with their online education experiences, with 43 items on the students' side and 39 items on the teachers' side.

Data collection and analysis
Electronic questionnaires were employed. The questionnaire for the students was in English and that for the teachers was in Chinese. In the questionnaires, it was clearly explained that the participation was completely voluntary and the aim was to investigate the international medical and nursing education. All participants gave written consent for their opinions to be published anonymously.
The data obtained from this study were analysed using IBM SPSS Statistics (version 24.0). Responses to the fivepoint Likert-scale questions ranged from "strongly disagree/very poor/very low/very little (1 point)" to "strongly agree/excellent/very high/very much (5 point)". The Chisquare test was used to determine the influence of the characteristics of students/teachers on the education satisfaction and to compare the experiences and expectations of online education between students and teachers. The Kruskal-Wallis rank-sum test was performed to identify the positive and negative factors influencing students' and teachers' online education satisfaction. A binary logistic regression model was performed to compare the influence of factors in different categories on the online education satisfaction.

Results
Information on the students' characteristics is provided in Table 1. In total, 316 international students at the university who had been receiving an online education were invited to complete the questionnaire and 230 responded, giving a response rate of 72.8%. Among all the participating students, 130 (56.5%) were Asian students and 100 (43.5%) were African students. Most of the students (71.3%) used the mobile phone for online learning. During the online learning time, 77 (33.5%) were staying inside China, and 153 (66.5%) were staying outside China; to be specific, 147 (63.6%) were in their home countries. Table 2 describes the teachers' personal characteristics. A total of 120 teachers who had been teaching IMSs/INSs online courses were invited to participate in the study and 95 of them responded, translating to a response rate of 79.2%. About 48.4% of the responding teachers were lecturers or teaching assistants. Fifty-one (53.7%) taught basic subjects and 83 (87.4%) undertook work in addition to teaching. The majority of them (74.7%) had no online teaching experience and the bulk of the teachers (80.0%) taught at home.   Table 3 shows the influence of the students' characteristics on their assessment of online education quality. For the purpose of discussion, students' years of study were divided into basic years and clinical years and their countries of origin were grouped into Asian and African countries. Overall, 36.5% of the students were positive about the online learning. More students in their clinical years (72.5%) were negative about the online learning effect than those in their basic years (58.7%) (P < 0.05). A higher percentage of African students (73.0%) were dissatisfied with online learning compared to their Asian counterparts (56.2%) (P < 0.01). In addition, the percentage of the dissatisfied students inside China (80.5%) was higher than that of dissatisfied students outside China (54.9%) (P < 0.01). The influence of the teachers' characteristics on their assessment of online education quality is shown in Table 4. Overall, 61.1% of the teachers were satisfied with the online education effect. Professional title was identified as a significant characteristic associated with teachers' satisfaction of online education (P < 0.01), while other characteristics were not. Pairwise comparison revealed that the percentage of the dissatisfied professors (71.4%) was significantly higher than that of dissatisfied associate professors (28.6%). Table 5 shows students' assessment of the factors influencing their satisfaction on online education, and 40 factors were found to be significant ones (P < 0.05). After comparing the mean ratings of each question from satisfied students and dissatisfied students, 9 factors were identified as negative factors for online education satisfaction and 31 factors were positive factors. Based on the ranking of the factors' mean value, the severity of the COVID-19 situation (Sa-01), the absence of experimental/practical classes (Sd-06), the uncertainty of the university-opening date and the following teaching arrangement (Sa-05), the severity of economic issues related to the COVID-19 (Sa-06) and the lockdown due to the COVID-19 (Sa-02) were the top 5 barriers to students' online education. However, the top 5 factors that were influential in facilitating success in their online learning included: well-accomplished assignments (Sb-10), adequate frequency to access the internet for online learning (Sb-11), adequate support and help from the university during the online learning process (Sd-10), adequate self-discipline (Sb-05) and adequate use of the course resources (Sb-13).

Factors affecting students' online education satisfaction
Furthermore, the influential factors were quite different for students inside China and those outside China ( Table 5). The top 5 beneficial factors for students inside China were the clarity of the online course objective (Sd-11), the playback support for the online courses (Sd-07), the capability of independent study (Sb-01), the quality of the course resources (Sc-06) and the easy use of the course resources (Sc-07). As for students outside China, the top 5 promoters were adequate frequency to access the Internet for online learning (Sb-11), adequate support and help from school during the online learning process (Sd-10), adequate self-discipline (Sb-05), adequate use of the course resources (Sb-13) and good administration of the online courses (Sd-01).
While there were no negative factors found to affect students inside China, the top 5 obstacles for students outside China were the severity of the COVID-19 situation (Sa-01), the uncertainty of university-opening date and following teaching arrangement (Sa-05), the sense of distance (Sb-07), the lockdown (Sa-02) and the severity of economic issues related to COVID-19 (Sa-06). Table 6 shows teachers' assessment of factors influencing their satisfaction with online education, and 17 factors Table 3 Students' personal characteristics affecting their online education satisfaction (n = 230) a 1st-, 2nd-and 3rd-year MBBS students and 1st-and 2nd-year nursing students were grouped into basic years, who studied basic sciences subjects b 4th-and 5th-year MBBS students and 3rd-year nursing students were grouped into clinical years, who were engaged in clinical studies were found to be significant ones (P < 0.05). Among them, 5 were negative factors-the sense of distance (Tb-10), the lockdown (Ta-02), the severity of the COVID-19 situation (Ta-01), the stressful workload for online teaching (Ta-05), and the absence of experimental/practical classes (Td-05). In the 12 success factors, the top 5 were: good administration of the online courses (Td-01), effective design and arrangement of the online courses (Td-02), good teaching environment (Ta-03), satisfying outcomes of students' quizzes (Tc-06) and satisfying tools for discussions (Td-10).

Crisis-, learner-, instructor-and course-related categories affecting online education satisfaction
All the factors were classified into 4 major categories according to their attributes, namely crisis-, learner-, instructor-and course-related categories. A binary logistic regression model was performed for multiple-factor analysis to determine the association of the related categories with the online education satisfaction (see Table 7). For all the students, their online education satisfaction was closely associated with the crisis and the instructors (P < 0.01). Moreover, factors associated with the crises (P < 0.05), instructor (P < 0.01) and course (P < 0.05) significantly affected students outside China, which was not the case for students inside China. And for teachers, their online education satisfaction was associated with the crisis and the learners (P < 0.01). Table 8 compares students' and teachers' opinions regarding their experiences and expectations of online education. Significant differences were found in their responses of the online education perceptions and expectations for the future delivery of education courses. Specifically, the percentage of the teachers who were satisfied with the online education effect (61.1%) was higher than that of the satisfied students (36.5%). After pairwise comparison, it was found that a higher ratio of teachers preferred blended education (53.7%) compared to the students (30.9%), while a higher proportion of students

Discussion
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 [25]. 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 [13]. 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. 2. Students' ratings of the questions did not comply with the normal distribution, so Kruskal-Wallis rank-sum test was performed to compare if there was any significant difference between the students who were satisfied with the online education and those who were not satisfied in each question 3. The symbol "/" indicated that there was no significant difference between the satisfied students and the dissatisfied students 4. The symbol " + " indicated that there was significant difference between the satisfied students and the dissatisfied students, and the factor was positively related with the satisfaction of online education (the mean rating of satisfied students was higher than that of dissatisfied students) 5. The symbol "−" indicated that there was significant difference between the satisfied students and the dissatisfied students, and the factor was negatively related with the satisfaction of online education (the mean rating of dissatisfied students was higher than that of satisfied students)  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 [32]. 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 [32]. 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 [33], which presented challenges to their online teaching conditions. Second, a massive number of courses had been transitioned from offline to online 1. Code of the questions: The letter T refers to the questions for teachers; the letters a, b, c and d represent 4 categories (crisis-related category, learner-related category, instructor-related category and course-related category), respectively 2. Teachers' ratings of the questions did not comply with the normal distribution, so Kruskal-Wallis rank-sum test was performed to compare if there was any significant difference between the teachers who were satisfied with the online education and those who were not satisfied in each question 3. The symbol "/" indicated that there was no significant difference between the satisfied teachers and the dissatisfied teachers 4. The symbol " + " indicated that there was significant difference between the satisfied teachers and the dissatisfied teachers, and the factor was positively related with the satisfaction of online education (the mean rating of satisfied teachers was higher than that of dissatisfied teachers) 5. The symbol "−" indicated that there was significant difference between the satisfied teachers and the dissatisfied teachers, and the factor was negatively related with the satisfaction of online education (the mean rating of dissatisfied teachers was higher than that of satisfied teachers) Table 7 Crisis-, learner-, instructor-and course-related categories affecting online education satisfaction The symbol "/" indicated that the particular category did not significantly affect the particular population's attitude towards the online education, so the related data were excluded from the binary logistic regression model for multiple-factor analysis

Categories
All  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. [11], 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 [35] that learning attitudes outweigh technology skills regarding online learning. Bernardo et al. [23] 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 [34], and the latter facilitates the development of the former [36].

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 [28], Malaysia [37], Ghana [38] and South Africa [39]. All the students in our study were learning online in LMICs. As documented by Frehywot et al. [12], 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 [40]. 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 [41]. 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 [42]. 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-toface contact and interactions with classmates as well as instructors are preferred for experimental hours [43] and the hands-on clinical operative experiences and direct patient care are indispensable [42]. 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 [44].

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 [45]. Instead, e-learning is more regarded as a supplement to support traditional didactic teaching [30] or a component of blended learning [28]. 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.

Conclusions
This study has identified the key factors which have influenced the satisfaction of international medical and nursing students and their teachers towards their online education in China during the pandemic. This information can be used to inform medical schools on how to improve their online teaching delivery in a similar crisis in the future and enhance their education outcome. The current COVID-19 crisis significantly affects the online education outcome of international students and teachers, whereas the influence might be in disparity according to the pandemic situation at their current places of residence in different countries. Medical schools are advised to take care of in-China international students' psychological status and create a more enjoyable learning environment for them, while also taking care of out-China international students who are studying from a far distance where they may be subject to the pressures from slow Internet connection and high data cost. In addition, it is suggested that universities in China need to collaborate collectively to connect with overseas medical schools and hospitals, so as to create practice opportunities for international students.