Health care providers have described inadequate knowledge to fully care for people who use unregulated psychoactive substances during hospitalization. Literature has revealed gaps in understanding health care providers’ perspectives of harm reduction and substance use education in hospital. Through an interpretive lens, this secondary analysis explores gaps which exist in current education and related factors needing to be addressed in hospital settings. This study was conducted across three hospitals in one city in southwestern Ontario with a sample size of 31. Using an ethnographic method of analysis themes emerged including the interconnection between the health care providers’ perspectives of the current state and desired state. Themes which emerged in both states include: (a) insufficient education, (b) lack of resources, (c) inconsistent policy, (d) culture of stigma and suboptimal care, (e) enhanced education, (f) resources, (g) policy change, (h) culture shift and optimal care. The findings of this study demonstrate the need for supportive policy, resources and enhanced harm reduction and substance use education to shift the current culture of care in hospital to better inform policy, practice, education, and future research.