Tehran University of Medical Sciences Iranian Journal of Psychiatry 1735-4587 0 0 2026 08 02 1 11 Sabreen Kareem Flayh Department of Pediatric Nursing, College of Nursing, University of Baghdad, Iraq. Adraa Hussein Shawq Department of Pediatric Nursing, College of Nursing, University of Baghdad, Iraq. 2026 05 30 2026 07 01 Objective: This study aimed to compare the effectiveness of virtual reality (VR) versus play therapy in reducing pre-procedural anxiety among children scheduled for cardiac catheterization, and to evaluate parental satisfaction with these interventions. Method: A randomized, assessor-blinded, pretest-posttest comparative trial was conducted at Al-Nasiriyah Heart Hospital between December 2025 and February 2026. A total of 75 children aged 3-7 years with congenital heart defects were randomly allocated into three equal groups (n = 25 each): VR (15 minutes of immersive 3D video), play therapy (15 minutes of coloring activity), and control (standard care). Anxiety was assessed using the Modified Yale Preoperative Anxiety Scale (mYPAS) at four time points (two pre-intervention and two post-intervention measurements). The outcome assessor was blinded to group allocation. Data were analyzed using analysis of covariance (ANCOVA) with Bonferroni-adjusted post-hoc comparisons to control for baseline age and anxiety differences. Results: The VR group demonstrated the lowest mean anxiety score post-intervention (mean = 5.04 ± 0.20), followed by the play therapy group (mean = 5.88 ± 1.33), while the control group maintained consistently higher anxiety levels (mean = 12.24 ± 1.39). ANCOVA, controlling for baseline anxiety and age, revealed a statistically significant main effect of intervention group on post-intervention anxiety scores [F 2, 70) = 38.24, P < 0.001, η² = 0.52]. Post-hoc pairwise comparisons with Bonferroni correction showed that, compared with the control group, both VR (P < 0.001) and play therapy (P < 0.001) significantly reduced anxiety. Furthermore, VR produced significantly greater anxiety reduction than play therapy (P = 0.03, Cohen's d = 0.83). Parental satisfaction was uniformly high across both intervention groups, with no significant difference between them (P = 0.568). Conclusion: Both VR and play therapy are effective non-pharmacological interventions for reducing pre-catheterization anxiety in children. VR demonstrated superior anxiolytic effects compared to play therapy, with a large effect size. Integrating VR-based distraction into routine pre-procedural nursing care may enhance pediatric procedural experiences and improve clinical outcomes. https://ijps.tums.ac.ir/index.php/ijps/article/view/4634 https://ijps.tums.ac.ir/index.php/ijps/article/download/4634/1346