There's an issue that films often seem to run into, where they choose to simply view the general narrative of a book they are adapting, rather than the narrator or any of the deeper nuances of the book. This happens all too often; entire characters might be removed, causing events to change their form, and eventually you wind up with a vastly changed narrative.
Ken Kesey disliked the film version of his first published novel, One Flew Over the Cuckoo's Nest. On an initial viewing, it might be difficult to see why. The battle of wills between Jack Nicholson's Randle McMurphy and Louise Fletcher's Nurse Ratched is depicted well, and the way he builds up his fellow inmates in her ward at the mental hospital to rebel against her is well-scripted, well-acted, and paced brilliantly, with everything seeming slow-paced until the rising tensions make it all explode into a flurry of action in the second half of the film, with a breakout from the asylum, the theft of a fishing boat, and eventually a huge drunken party in the ward.
The filmic Nurse Ratched has a rather chilling way about her, being able to use just a few levelly-spoken words in a sort of 'mom voice' to utterly destroy any thoughts of changing their situation that her patients might express, keeping them in their places. She holds all the power, until McMurphy appears and starts to disrupt the ward, but her power is ultimately limited to her little fiefdom.
The novel's version of Nurse Ratched is far, far more daunting of an opponent, however, and that is amplified in the text by how she is being viewed through the eyes of a hallucinating, schizophrenic narrator. The Big Nurse is less a human and more the avatar of the Combine, a vast machine which, in "Chief" Bromden's eyes, is working to grind everything and everyone in America down into a homogenous sameness that makes everything run absolutely perfectly, and that sees variation as a danger to the system.
It is spelled out rather clearly, both by Bromden's narration and by the words of other staff in the book, that the Big Nurse actually rules over the entire hospital. It's stated that hiring and firing is largely down to her preferences, that she uses dangerous and invasive treatment methods (such as electroshock and icepick lobotomies) punitively rather than therapeutically, that even the doctors are afraid of her. Bromden sees this as her being a sort of giant; while he may be physically much larger than she, his spirit was broken long before he set foot in the asylum, his schizophrenic hallucinations beginning when he saw how the loss of his tribe's lands and way of life destroyed his father (the tribal chief), his deaf-mute affectation a self-defensive measure to keep himself from her attention, and his view of other's size is based on their force of will. He sees everything through the lens of the Combine, orderlies viewed as robots, the Big Nurse's medical bag full of gears and machine parts, everything moving about on wires and strings to do the bidding of the machine, Ratched herself having a literally-molded face, her lips standing out garishly, her eyes the only sign of what is going on in her head.
This, then, sets up the ultimate nature of the novel's struggle: Randle McMurphy, the Coyote-like trickster who is armed with a quick wit, an irreverent attitude, and a need to assert his absolute individuality, enters the ward and clashes against the god-like figure of the Big Nurse, with her emotion-hiding face and gender-obscuring uniform. The men on the ward make it clear what the stakes are in this conflict: McMurphy certainly can't win the war, and if he loses a single battle, he loses everything.
The general plot beats of the book do mirror the film, but in a way that leaves the film's version of the battle between McMurphy and Ratched seem watered down. Where McMurphy's attempts to get TV privileges swapped around for the ward to watch baseball are a single incident on the film, it is a repeated event in the book, his act of civil disobedience in pretending to watch on the blank screen and giving a running commentary recurring in a way that deliberately draws attention for the other staff to the taking of power it represents. Rather than simply sneaking out for the fishing trip that he takes the other inmates on, he plans it in the open, ostentatiously flaunting it in front of Ratched, and even drawing one of the doctors into it.
Perhaps the most important difference, the one that matters most, is in the final showdown between the two, with McMurphy trying to choke the life out of Ratched. The film shows the aftermath of this being the nurse in a cervical collar, calmly reasserting her control over the ward, McMurphy's self-sacrificing attack on her having done little more than push Chief Bromden to make his escape on the night, after putting McMurphy out of his misery.
The book's version of this is vastly different, and serves to make McMurphy much more of a heroic figure. His attack on the Big Nurse is much more intense, and allowed to last longer; the orderlies don't move to pull him off, and in the struggle her clothing is torn open, revealing her femininity in that moment of rage on McMurphy's part, but his attack isn't sexual; rather, it's an assault on Ratched's very godhood within her realm. The aftermath includes a far kinder nurse in her position until she recuperates enough to return, allowing the patients to begin their escapes, the voluntary patients checking themselves out or being transferred, leaving only those who can't leave to witness the ultimate destruction of her power, McMurphy's attack leaving her communicating via writing as she has completely lost her voice. Where the film ends with Ratched maintaining the status quo, seemingly without any change to her confidence, the novel's McMurphy succeeds in bringing her down, the remaining patients very openly mocking her impotent attempts to control them with writing.
That said, McMurphy has sacrificed himself in both cases, and where the film has him surgically lobotomized, a presumably controlled action (though the effects are clear enough), the book has him having received what honestly looks like it was a double icepick procedure, with both eyes left bruised shut. It's even less clear whether anything of McMurphy remains within the husk that is rolled back into the ward; Bromden's mercy killing is less giving the man rest than putting down the spiritless body so that Ratched can't use it as a symbol of what happens to those who resist her.
Even Chief Bromden is changed by the experience; by the end of the book, he has begun to speak openly to the other ward inmates, has openly stood up to the orderlies (breaking one of their arms in the scuffle that earns an electroshock treatment for himself and McMurphy), and feels himself large enough that when he tears the hydrotherapy controls from the floor and throws them through the window to effect his escape from the confinement, he has no doubt that he's a big enough man now to do it, to return to the world, to see how the remnants of his tribe are struggling against the Combine in their own way, to return to the lands of his youth.
He's been away a long time.
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