Mythily Rajaram is a nurse at Rhode Island Hospital who was recruited from India. “We can be good decision-makers in deciding patient care,” she says. The Providence Journal / Andrew Dickerman

If you end up in the hospital these days, you may find that the nurse caring for you speaks with an accent from half a world away.

Perhaps at your bedside you’ll meet Mythily Rajaram, 29, who left southern India late last summer for a night job at Rhode Island Hospital — fulfilling both her own ambition and the hospital’s need.

Or, if you’re in the coronary-care unit, you may find yourself in the care of Radha Rengan, 31, who is also from southern India, and who explains, “Coming to the U.S. is the dream of all Indian nurses.”

They are among 20 foreign-educated nurses now working at Rhode Island Hospital, in Providence.

Kent Hospital, in Warwick, has 31 foreign nurses.

These hospitals have joined a national trend to look overseas for trained and experienced nurses to fill the dire nursing shortage at home.

So far, the number of foreign nurses in Rhode Island is small. Of the 20,553 nursing licenses, only 79 belong to foreign-trained nurses, some of whom probably have not yet arrived. Rhode Island Hospital’s 20 foreign nurses work among 1,800 bedside nurses at the hospital.

But, here as elsewhere, the trend is clearly growing — held in check, at least for now, by limits on the number of visas the State Department will give out. Rhode Island Hospital has offered jobs to 133 additional foreign nurses who are waiting for visas. Kent Hospital has 26 foreign nurses “on the way.”

Nationwide, 12 percent of those who took the qualifying exam for a nursing license last year were educated overseas.

Recruiting foreign nurses is nothing new: hospitals have always looked abroad during periodic nursing shortages. But the difference today is that there’s no end in sight. Older nurses are retiring or seeking reduced hours, nursing schools are unable to produce graduates fast enough and the demand can only soar as the population ages.

The trend raises concerns — about the well-being of the nurses uprooted from distant cultures, the effects on the nations whose best nurses are being lured away and especially about the wisdom of going overseas to solve a domestic problem.

“It’s probably easier to go to India than to figure out a long-range plan for work-force development,” said Linda McDonald, president of the United Nurses and Allied Professionals, the union that represents nurses at Rhode Island Hospital. “We think this is the wrong way to address the problem.”

Cheryl A. Peterson, senior policy analyst at the American Nurses Association, noted that the problems underlying the nursing shortage have not been addressed. “Do we have a nursing-education system in place that allows us to educate a sufficient number of nurses to meet our future demand? Do we have a work environment that retains those nurses that we have educated?” she said. “If the United States could say, yes, we have both those things but still can’t meet our demand … then I would buy into that we need foreign-educated nurses. … But we aren’t there.”

HOSPITAL OFFICIALS say that hiring foreign nurses is their best option in a tough situation. They say they are doing all they can to boost the local work force for the future — but they need trained and experienced nurses today.

For Rajaram and Rengan, coming to Rhode Island was the culmination of years of studying, working and waiting. In India, they explained, nurses choose one of two professional paths: get a diploma to work in government hospitals or earn a bachelor’s degree to work overseas. The nurses seeking foreign employment typically train at private hospitals such as the Apollo chain — hospitals that cater to international clients, including many Americans looking for lower-cost care. Rajaram and Rengan say that nurses in India work 48 hours a week at wages much lower than in the United States, and they don’t have the same opportunities for career advancement.

In 2005, Rengan and Rajaram were among 90 Indian nurses who met, individually, with a team from Rhode Island Hospital. The Rhode Islanders quizzed them about hypothetical clinical situations. The nurses and administrators also visited the schools and hospitals where the nurses trained and concluded that their training was equal to that received in the United States.

Before they can work in the United States, foreign nurses must get cleared by the Commission on Graduates of Foreign Nursing Schools, which does a course-by-course check of their schooling to make sure their education is identical to that of an American-trained nurse. They have to take a nursing proficiency test, an English test and the NCLEX licensing exam that all nurses must pass.

Rengan and Rajaram cleared all those hurdles and were among 30 nurses offered three-year contracts to work evening or night shifts at Rhode Island Hospital, where they would join the nurses’ union and be covered by the union contract. All 30 accepted the offers. But the visas for immigrants from India had been exhausted. Two years later, their names had still not reached the top of the list.

This had happened before: in 2003, Rhode Island Hospital hired 23 Filipino nurses who had been working in Ireland. Only three made it here — and that was in 2006. More recently, the hospital offered jobs to 100 nurses who are working in England but who originally came from other countries — primarily the Philippines and India, but also Africa, the Caribbean and elsewhere. None has arrived.

Even with the visa difficulties, says Louis J. Sperling, vice president of human resources at Rhode Island Hospital, foreign nurses remain preferable to hiring travel nurses, who work for agencies, stay for a short while and cost much more. According to Sperling, recruiting a foreign nurse costs about the same or less than recruiting an American nurse ($35,000 to $40,000 per nurse).

Sperling hires 160 new graduates each year, nearly all from Rhode Island. But he needs more than that, and to staff a specialized teaching hospital, he also needs nurses with experience.

KENT HOSPITAL took a different approach that yielded somewhat faster results. Instead of hiring the nurses directly, it contracted with an agency. The nurses are employed by the agency, O’Grady Peyton, for a minimum of 3,000 hours, or about 18 months, after which they can apply for employment at the hospital. Their salaries are the same as Kent nurses, who are not unionized; their benefits through the agency slightly less.

Since the program started in February 2005, 54 nurses from around the world have come to Kent through the agency, says David Campbell, vice president of human resources. Twenty-three left to join relatives or take jobs in other parts of the country, or to return to their home countries. The hospital hired 16 at the end of their contracts, and 15 are still working at Kent under contract with O’Grady Peyton. Kent officials say the foreign nurses have worked out well and the hospital would love to hire more — but the frustrating restrictions on visas have put the program on hold.

For Rajaram and Rengan, it took until late last summer — two years after they were offered jobs by the Rhode Island Hospital team — for their visas to be approved. They landed at Logan Airport, where an agent working with the hospital met them and took them to their temporary home, provided by the hospital, at Extended Stay Suites in East Providence.

They were among 16 Indian nurses who started working at Rhode Island Hospital in September (one more arrived in December). Both were joined by their husbands. Rajaram also brought her sons, now 3½ and 1.

Despite the years of planning, the nurses faced unexpected logistical obstacles when they arrived. Social Security numbers weren’t issued in time, says Kevin W. von See Dahl, the hospital’s new hire coordinator. The Indian nurses had difficulty finding apartments because they had no credit history and landlords required them to find someone to cosign their leases. There were no buses running at 11 p.m., when many started or ended their shifts.

But gradually, the nurses found their way, joining other people from their home country. Most have moved into an apartment complex in East Providence that is already home to an Indian community. Although Hindu, Rangan found a Pentecostal church in Milford, Mass., with many Indians in the congregation, and someone there cosigned her lease. Coworkers offered rides in the wee hours.

Like all nurses hired at Rhode Island Hospital, the Indian nurses face six months probation. If a nurse doesn’t work out in the first six months, she has a green card and the ability to look for work elsewhere. If a nurse wants to leave before the three-year contract is up, she would have to break her contract.

But so far, it looks like everyone is staying. Asked how the nurses were adjusting, von See Dahl says there have been ups and downs, but most are content and committed to their new jobs and new country. The biggest problem, he says, is that their husbands have had trouble finding jobs.

One nurse suffered terribly when her brother died and she couldn’t afford to go home to be with her family. “Even she never said, ‘I’m absolutely miserable,’ ” von See Dahl says. “Even with the bumps along the road, even with transportation, taxes, finding doctors, dentists, even with moving, I haven’t had anybody say, ‘I want to go home.’ ”

IN A RECENT INTERVIEW, Rajaram and Rengan echoed von See Dahl’s views. Speaking in fluent, accented English, both said they are happy to be here and plan to stay. Sure, they’ve had trouble finding food they like, and the cold has been hard to take. Their husbands, both highly trained professionals, are still looking for jobs. But von See Dahl and fellow nurses have helped them through the logistical snarls, showing them where to shop, scouting apartments, offering rides and other assistance. “I appreciate the helping tendencies in Americans,” says Rajaram, who also finds Rhode Island “a very quiet and calm place.”

In the hospital, they said, the care they provide is similar, but the tools are different — more up-to-date. The patients’ health issues are also similar, except that the morbid obesity frequently seen here is extremely rare in India. The big difference is in the role of nurses here — they have more independence and responsibility, and are expected to question doctors’ orders if anything looks wrong to them. “In India, if a doctor says to do something, you absolutely have to do it,” Rengan says.

“We can be good decision-makers in deciding patient care,” says Rajaram.

“We can shine better,” says Rengan. Indeed, one of the reasons they came here is to become better nurses.

“Everything is good,” Rajaram said. “That comes from my heart, not just my mouth.”

“We are fully satisfied,” agreed Rengan. “We are staying here.”

Sperling says he has not heard of any complaints from staff members or patients about the new nurses, or from the nurses themselves.

But McDonald, the union president, said the experience has been mixed. “Some are doing great and some are not,” she says. “I know a lot of them are homesick. I don’t think they were prepared for how expensive it is to live here. How they’re fitting in — some are easily fitting in, some of them are having trouble.”

Although the Indian nurses have passed English proficiency tests, “you have to listen harder” to understand them, McDonald said. “Rhode Islanders aren’t used to talking to somebody with a different language.”

But what irritates McDonald is that the hospital is spending money to find nurses overseas. She’d rather see it go to training programs in Rhode Island and improving the work environment for nurses. As elsewhere, the nursing schools here don’t have enough professors, or adequate facilities, to teach all the people who want to become nurses. Nursing professors are paid less than many practicing nurses who have lesser degrees, making it difficult to attract more people to teaching.

“Don’t we have the resources, the talent and the brains to figure out how to educate our high school students in Rhode Island and [attract] them into health-care fields and figure out how to work with schools to get more educators?” McDonald asks. “It’s not hard. Pay them a little more.”

Sperling answers that Lifespan, the company that owns Rhode Island Hospital, has invested heavily in boosting the nursing schools, including lending its own nurses to help teach and its own facilities for clinical learning. “For me to keep pace with what we need, I need to hire 320 nurses a year. Where are we going to get them?” he asks.

Campbell, Kent’s human-resources chief, tells a similar story. “No matter what we do in all these programs in the state, that’s not enough,” he says. “We’re promoting all of these other avenues. When you look at what your need is and what your supply is, you have to fill the gap.”

The nationwide need to fill that gap has spawned a burgeoning industry of nurse-recruiting companies. But no one has been tracking what’s happening or making rules, says Patricia Pittman, executive vice president at AcademyHealth, a Washington, D.C., think tank that seeks to bring together health services researchers and policy makers.

Through focus groups and interviews, AcademyHealth documented anecdotes of abusive practices, such as not letting foreign nurses have a copy of the contract they’ve signed or paying them less than other nurses in the hospital. Concerns have also been raised about drawing the nurses away from Africa and Latin American, where many people cannot get medical care.

AcademyHealth has convened a group to develop guidelines for foreign nurse recruiting. “This is bigger than we thought,” Pittman says. “We need to catch up in research. We need to catch up in policy.”

Once nurses make their way to the United States, they rarely return to their home countries. Although there is no data, Pittman says, “People believe almost none go back.”

“It’s a fact of life,” says Donna Policastro, executive director of the Rhode Island State Nurses Association, “that nurses are going to come from other countries to take care of us.”

ffreyer@projo.com