Nurse Ratched, whose power is expressed in bluntly sexual terms despite her attempts to deny her sexuality, maintains her position as the sloe voice of authority on the ward by suppressing the patients' laughter. The men under her jurisdiction use sexual references when talking about her, and after the first group therapy session the new admission R.P. McMurphy calls her a "ball-cutter." The nurse attempts to hide her sexuality, and the schizophrenic Chief Bromden, the narrator of the novel, first brings the reader's attention to this denial in saying, "A mistake was made somehow in manufacturing, putting those big, womanly breasts on what otherwise would have been a perfect work, and you can see how bitter she is about it." (Kesey 11) Nurse Ratched's ultimate authority on the ward stems from the fact that she controls people who would normally be her superiors, namely Dr. Spivey, who Dale Harding says is, "'exactly like the rest of us. . .completely conscious of his inadequacy. He's a frightened, desperate, ineffectual little rabbit, totally incapable of running this ward without our Miss Ratched's help and he knows it. And, worse, she knows he knows it and reminds him every chance she gets.'" Her ability to dominate the patients is a result of her controlling their laughter. McMurphy notices that,

     . . .the first thing that got to me about this place, that there wasn't anybody      laughing. I haven't heard a real laugh since I came through that door, do you know      that? Man, when you lose your laugh you lose your footing. A man go around lettin'      a woman whup him down till he can't laugh any more, and he loses one of the      biggest edges he's got on his side. First thing you know he'll begin to think she's      tougher than he is. . . (Kesey 65)

      Nurse Ratched also uses outside influences to help her control her patients, as is the case with Billy Bibbit, whose mother is friends with the nurse; together they work to manipulate Billy.