The provision in hospitals of traditional, complementary and alternative medicine (TCAM), as recognized by the World Health Organization, is now widespread in many of the world's healthcare systems. As a significant part of integrative medicine (IM) or healthcare (IHC), research has now begun to focus on the varied parameters of hospital-based TCAM, however, little research has been conducted on the topic in the Canadian context. Drawing on a multi-site case study of four Canadian hospitals, qualitative observation was conducted at hospital sites, and interviews were conducted with senior hospital leaders and biomedical and TCAM hospital practitioners. The main focus of inquiry was to obtain the views of hospital leaders on the topic of incorporating TCAM, and to examine the motivations for TCAM inclusion, economic dimensions and level of integration between TCAM and biomedicine. Hospital leaders were both highly critical of TCAM and cautiously supportive. Inclusion of TCAM was directly related to hospital leadership and institutional relationships, while TCAM practitioners remained marginalized due to economic, geographical, political and epistemological barriers. Although signs of integration were apparent, significant challenges remained that prevented TCAM practitioners from operating as fully-fledged hospital providers. An integrated change strategy is needed that engages the TCAM professions in mainstream interprofessional education and training opportunities, and that also addresses wider structural and political barriers.