“In this hospital,” Harding says, “the doctor doesn’t hold the power of hiring and firing. That power goes to the supervisor, and the supervisor is a woman, a dear old friend of Miss Ratched’s[.]”

Early on, McMurphy questions why Dr. Spivey doesn’t fire Nurse Ratched, and Harding explains that she holds ultimate authority. A doctor normally wields authority over a nurse, and in this era, a man typically has more power than a woman, but here the power structure has reversed. This topsy-turvy world has deep significance: Nurse Ratched has created a wholly abnormal environment. The struggle for power will go beyond a test of wills between her and McMurphy—to win, he will actually have to normalize the ward by delegitimizing Nurse Ratched.

The Big Nurse is able to set the wall clock at whatever speed she wants by just turning one of those dials in the steel door; she takes a notion to hurry things up, she turns the speed up, and those hands whip around[.]

Bromden ascribes to Nurse Ratched the ability to control time itself, indicating her role as absolute ruler of the ward. Nurse Ratched’s authority partially stems from her role as head nurse, but more importantly, it relies on the hospital community’s docile acceptance of her ultimate power. Bromden and the other residents contribute to this hierarchy when they credit Nurse Ratched with almost godlike powers. Their acquiescence relieves them of any personal responsibility to stop her authoritarianism and demand a modicum of autonomy—and the accountability that comes with such self-direction—for themselves.

All this morning I been waiting for them to fog us in again. The last few days they been doing it more and more.

Bromden believes that the authorities on the ward purposefully create a fog that allows them to control the patients. To Bromden, the fog renders the men incapable of seeing or thinking clearly. His allegory represents the officials’ efforts to keep the inmates submissive and compliant to Nurse Ratched’s domination. The fog can result from the men’s mental state or medication or from electric shock therapy given to the men by the medical team. Once McMurphy arrives on the ward, Bromden experiences the fog less frequently because McMurphy has upended the power structure and Bromden begins to see more clearly again.

“I was picked up for drunk and disorderly, and I been here eight years and eight months,” he said.

While at the swimming pool, another inmate reveals to McMurphy that after an arrest that took place eight years previously, he was committed against his will. The inmate has no means to bring about his own release and he directly blames Nurse Ratched for keeping him at the hospital. While the man indeed may be mentally ill—he believes he broke his arm in a recent pro football game—his situation demonstrates to McMurphy the complete power that Nurse Ratched now holds over him. She controls anyone and anything within the ward.

First Charles Cheswick and now William Bibbit! I hope you’re finally satisfied. Playing with human lives—gambling with human lives—as if you thought yourself to be a God!

Toward the end of the book, after Billy kills himself, Nurse Ratched lashes out at McMurphy, blaming him for Billy’s suicide as well as Cheswick’s. This confrontation climaxes the long struggle between Nurse Ratched and McMurphy. His time in the hospital has been a game of one-upmanship in which she tries to keep him subservient and he tries to rile up the men. Now, however, in a dramatic shift, she attributes to him the power of life and death. Her own words indicate her realization of the new limits to her absolute power.