Despite excellent nursing practice, one also finds that adverse nursing events, bad practice, and inadequate policies continue. A general failure to speak up with concerns can be usefully understood in terms of the psychological concept of „denial“ and an organisational culture of denial. Good quality nursing requires more than competent clinical skills. It requires the courage to speak up and raise concerns, thereby helping to influence policy and foster an organisational culture of openness. An awareness of the strategies of denial, and of the strategies of its opposite (openness), may enhance nursing.