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BACKGROUND : The hospital reform of 2002 organized Norwegian hospitals into health enterprises (independent legal subjects) and transferred overall responsibility from the counties to the central government (also the owner of the hospitals). The reform aimed at clarification of responsibility levels, improved access for all and more effective use of available resources. The new organization requires that medical professionals to a larger extent than before relate to professional leaders without medical competence; there is therefore an inherent risk of making the budget balance more important than ethics and the profession itself. We wanted to study whether the reform influenced the physicians' perception of professional right of voice. MATERIAL AND METHOD : In 2000 and 2004, a representative panel of 897 physicians responded to four statements about perceived (graded) professional right of voice related to putting forward criticism; two statements concerned the perceived risk of sanctions from their immediate professional and administrative superiors and two statements concerned the risk of heavy personal strain and having to find another job. RESULTS : A substantial proportion of physicians found it difficult to present criticism to superiors. 24 % perceived a risk of sanctions from professional superiors and 49 % from administrative superiors, 68 % felt they risked heavy personal strain and 29 % felt they would have to find another job. There was a statistically significant increase in four variables from 2000 to 2004. INTERPRETATION : There is a clear tendency for hospital doctors to experience increased difficulties in reporting sub-standard conditions at their work. This represents a threat to patient safety, and is a signal to the administrative leaders to improve their dialogue with the physicians.

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