Purpose: The purpose of this paper is to explore how teachers' approaches to teaching and conceptions of teaching and learning with educational technology influence the implementation of three-dimensional virtual worlds (3DVWs) in health care education. Design/methodology/approach: Data were collected through thematic interviews with eight teachers to elicit their approaches to teaching in a 3DVW and their conceptions of teaching and learning with technology in online health care education. Findings: Results indicate that teaching in 3DVWs necessitates the adoption of a student-centred approach to teaching. The teachers' underlying approaches to teaching and learning became evident in their student-centred approach and use of problem-based activities. The immersive, social nature of the environment facilitated the creation of authentic, communicative learning activities created by the health care teachers and was in alignment with their disciplinary approaches to teaching and learning. Research limitations/implications: The sample size of the study is relatively small which limits the degree of external validity and generalisability of the results. Practical implications: If sustainability of 3DVWs is to be achieved, academic development activities for teachers and their communities of practice may be necessary to support conceptual change and facilitate a shift to student-centred teaching where necessary. Originality/value: There is limited research concerning the relationship between teachers' approaches to teaching and the use of educational technologies, in particular the implementation of 3DVWs.